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SURCxICAL   DIAGNOSIS 


SUJRG1CAL  DIAGNOSIS 


BY 

ALEXANDER    BRYAN   JOHNSON,   Ph.B.,  M.D. 

PBOFESSOR  OF  CLINICAL  BUEGEEV    IN   THE  COLUMBIA    I  mvkksity    MEDICAL  COLLEGE; 
ATTENDING   SURGEON   TO  THE    NEW    YORK    HOSPITAL;    VISITING!   BUBGEON    TO  THE 
MOUNT  MOBIAH   HOSPITAL;   CONSU  LTING  si  KGEON  TO  ST.  JOSEPH' 8  HOSPITAL, 
FAR   ROCKAWAY;    FELLOW   OP  THE   AMERICAN   SURGICAL   ASSOCIA- 
TION;   MEMBEB  OP  THE   NEW    VnKK   BUBGICAL  SOCIETY 


VOLUME   I 

WOUNDS   AND  THEIR   DISEASES  •  DISEASES  OF  THE  SOFT  PARTS   AND   OF 

THE    BONES  •  TUMORS  •   FRACTURES  AND  DISLOCATIONS  •  SYPHILIS 

THE    X    RAYS  •  THE    HEAD  AND  NECK  •  THORAX   AND    BREAST 

THE   ABDOMEN    IN    GENERAL  •  THE   PERITONEUM   AND 

INJURIES  OF  SPECIAL  ABDOMINAL  ORGANS 


WITH    ONE  COLORED    PLATE  AND    TWO    HUNDRED   AND    FIFTY-SEVEN 
ILLUSTRATIONS  JN   TEXT 


NEW    YORK     AND    LONDON 

D.     APPLETON     AND     COMPANY 

1909 


v.    I 


Copyright,  1909,  by 
D.    APPLETON   AND  COMPANY 


PRINTED   AT   THE   APPLETON    PRESS 
NEW    YORK,    U.    S.    A. 


TO 

DOCTOR  CHARLES    McBURNEY 

THE    GREATEST    SURGICAL     DIAGNOSTICIAN 

THE    AUTHOR    HAS    EVER    KNOWN 

THIS    WORK    IS   DEDICATED 

AS    A    TOKEN    OP    HIGH    ESTEEM    AND    IX 

GRATEFUX   REMEMBRANCE 


J'  It  K  V  A  (J  k 


L\  this  work  the  author  has  attempted  to  treat  the  suhjecl  of  "Surgical 
Diagnosis"  upoB  fairly  broad  lines.  It  has  seemed  to  him  that  the  practical 
value  of  such  a  treatise  would  be  increased  it,  in  addition  to  a  description  of 
methods  of  examination  ;in<l  a  relation  of  signs  ami  svmptoms,  there  were 
added  some  pathological  data,  as  well  as  brief  histories  of  illustrative  cases. 
In  carrying  out  this  idea,  however  imperfectly,  he  hopes  he  may  have  suc- 
ceeded in  giving  to  the  medical  profession  a  book  which  shall  be  at  once  a 
help  to  those  who  desire  to  study  the  subject  of  surgical  diagnosis,  as  well 
as  a  direct  aid  to  the  physician  and  surgeon  in  arriving  at  a  correct  diagnosis 
in  the  individual  case.  The  work  embodies  to  some  extent  the  impressions 
gained  during  an  experience  extending  over  a  period  of  nearly  twenty-five 
years,  spent  in  the  surgical  wards  of  three  hospitals  in  the  city  of  New  York — 
namely,  Bellevue,  the  Roosevelt,  and  the  New  York  Hospital. 

In  preparing  this  work,  the  author  has  had  constantly  in  mind  the  needs 
of  the  practitioner  of  general  medicine,  and  it  is  to  him  especially,  he  believes, 
that   this  work  will  be  found  valuable. 

The  author  desires  to  express  his  gratitude  to  the  following  gentlemen 
for  permitting  him  to  use  illustrations  from  their  publications:  Dr.  Francis  S. 
Watson,  of  Boston;  Dr.  George  Woolsey,  Dr.  Pearce  Bailey,  Dr.  M.  A.  Starr, 
Dr.  F.  T.  Brown,  and  Dr.  Frank  Hartley,  of  New  York;  Dr.  Harvey  Cushing 
and  Dr.  Howard  Kelly,  of  Baltimore. 

The  following  gentlemen  have  been  kind  enough  to  give  to  the  author 
photographs  of  their  own  cases,  or  to  permit  him  to  use  such,  some  of  which 
are    reproduced     in    the    text:     Dr.    Charles    L.    Gibson,     Dr.     Ellsworth     Eliot, 

Dr.  Francis  W.  Murray,  Dr.  Lucius  W.  Hotchkiss,  Dr.  James  < '.  Aver.  Dr. 
Benjamin  S.  Barringer  (a  number  of  original  drawings  of  patients  and 
specimens").  Dr.  Lewis  A.  Conner,  Dr.  Lewis  A.  Stimson,  Dr.  P.  K.  Bolton, 
Dr.  William  A.   Dtfwnes,   Dr.   Eugene  Pool,  Dr.  dame-   \.   Bitzrot. 

vii 


viii  PEEFACE 

The  author  wishes  especially  to  express  his  thanks  to  Dr.  Charles  E.  Farr. 
For  the  past  five  years  Dr.  Farr  has  taken  photographs  of  nearly  every  case 
entering  the  ]STew  York  Hospital  which  could  be  of  use  in  this  book,  when  it 
was  practicable  for  him  to  do  so.  A  small  proportion  only  of  these  could  be 
utilized  for  reproduction  as  illustrations.  In  many  instances  the  condition 
of  the  patient  forbade  more  than  a  hurried  snapshot  under  unfavorable  con- 
ditions of  light,  and  for  this  reason  the  results  have  not  been  such  as  could 
be  utilized  in  this  work.  The  pictures  have  been  taken  of  medical  and  surgical 
cases  alike  entering  the  services  of  the  physicians  and  surgeons  on  duty  in 
the  hospital,  and  I  desire  to  thank  these  gentlemen  in  general,  as  in  a  pre- 
vious paragraph  I  have  done  by  name,  for  permitting  me  to  use  the  material 
in  their  respective  services.  A  certain  proportion  of  the  photographs  were 
taken  by  the  author  himself,  as  well  as  many  of  the  X-ray  pictures. 

The  author  wishes  to  thank  Dr.  James  H.  Kenyon  for  reading  and  cor- 
recting the  manuscript,  and  for  aid  in  many  other  ways. 

The  author  desires  especially  to  express  his  gratitude  to  Dr.  Charles  Mc- 
Burney  for  a  large  collection  of  photographs  accumulated  during  his  long  and 
distinguished  career.  He  also  wishes  to  thank  him  for  the  advantage  enjoyed 
throughout  a  period  of  many  years  by  a  close  association  with  him  in  surgical 
work,  thereby  enabling  the  author  to  collect  many  of  the  data  of  surgical 
diagnosis  embodied  in  this  work. 

He  wishes  to  thank  Prof.  George  S.  Huntington,  the  head  of  the  anatom- 
ical department  of  the  Columbia  University  Medical  College,  for  many  personal 
communications  in  regard  to  topographical  anatomy,  and  for  his  kindness  in 
permitting  the  author  to  utilize  his  article  on  "  The  Genetic  Interpretation 
and  Surgical  Significance  of  Some  Variations  of  the  Genito-urinary  Tract" 
in  the  section  devoted  to  the  Congenital  Anomalies  of  the  Kidney  and  Ureter. 

The  author  wishes  to  express  his  gratitude  to  his  sister,  x\lice  G.  Johnson, 
and  to  his  wife,  Louise  T.  W.  Johnson,  for  practical  aid  and  encouragement 
throughout  the  performance  of  a  long  and  tedious  task. 

Alexander  B.  Johnson. 

12  East  Fifty-eighth  Street, 
New  York  City. 


CONTENTS 


CHAPTER   1 
WOUNDS 
BtTBCD  rANBOUS    I  NJ1   EUES 

I'iimi>i  n    \\D    Lacerated   Wounds      .... 

[ncisbd  Wounds 
I'imii  i,i  d  Wounds 
Poisoned  Wounds    . 

Snake  Bites  . 

Poisoned  Arrow  Wounds 

The  Bites  mi* I  Stings  <>l'  Insects 
( ii  nshot  Wounds     .... 

I.  Wounda  Produced  by  Modern  Military  Rifles  and  Pistols 

II.  Wounds  Produced  by  Rifles  and  Rifled  Pistols   Loaded  w 
Soft-lead  Bullets     . 

III.  Wounds  Produced  by  Shotguns 

IV.  Wounds  Produced  by  Artillery 

Eemorrhaqb 

Shock    


th    Black 


Powder 


PAOI 

•J 

5 

B 

9 

12 

12 

_'l 

•_>•_> 

23 
24 

41 
13 
16 

17 
57 


CHAPTER   II 

the  diagnosis  of  the  diseases  caused  by  the  pus  producing  bacteria 

Varieties  of  Pus-producing  Organisms 

Mi  i hods  of  Obtaining  and  Caking  for  Pathological  Material 
Varying  Severity  of  Pyogenic  Infections    .... 
Pathological  Character  ov  Pyogenic  Bacteria  . 
Occurrence  of  Pyogenic  Germs  in  Various  Tissues 
Sources  of  Bacteria  in  Pyogenic  Infections 
Toxic  and  Other  Effects  of  Pyogenic  Organisms 
The   Diagnosis  of  Localized  Foci  of  Sititua TION   (Abscess) 
Physical  Signs    IND  Symptoms  of  Acute  Abscess 

Diseases  tu-   Wounds 

Aseptic  Wound  Lever,  Sapremia,  Septic  Intoxication.  Septicemia.  Pyemia. 
Combinations 

en  \ptlk    in 


ind  Their 


60 
66 
tw 
67 

OS 

71 
72 
79 
79 

85 


special  diseases  of  wounds 

Erysipelas 120 

Tetanus 122 

Rabies 126 

Anthrax 135 

Actinomycosis 137 

Madura  Foot 142 

Erysipeloid ...  143 

Glanders ...  14-4 


x  CONTENTS 

CHAPTER  IV 

SURGICAL   TUBERCULOSIS   AND   DIAGNOSIS   OF   DISEASES   OF   JOINTS 

PAGE 

Surgical  Tuberculosis 147 

Tuberculosis  of  the  Skin 150 

Tuberculosis  of  the  Mucous  Membrane 152 

Tuberculosis  of  the  Lymph  Glands 153 

Tuberculosis  of  the  Tendons,  Tendon  Sheaths,  Bursse,  and  Muscles 156 

Tuberculosis  of  Bone 157 

Tuberculosis  of  Joints 159 

Differential  Diagnosis  of  Tuberculosis  from  Certain  Other  Diseases  of  the 

Joints 167 

Syphilis  of  Joints 171 

CHAPTER   V 

DISEASES   OF   BONES 

Acute  Osteomyelitis 179 

Subacute  Osteomyelitis 183 

The  Subsequent  History 184 

Periostitis  Albuminosa  and  Sclerosing  Osteomyelitis     .        ...        .                .        .  185 

Periostitis 186 

Circumscribed  Osteomyelitis 187 

Tuberculous  Osteomyelitis 188 

Syphilis  of  Bone 189 

Rachitis 193 

Osteomalacia 196 

Osteitis  Deformans 196 

Acromegaly 197 

Leontiasis  Ossium 198 

CHAPTER    VI 

DISEASES   OF   THE   SOFT   PARTS 

Gangrene 199 

Moist  Gangrene — Traumatic  Gangrene 201 

Malignant  Edema — Gangrene  Foudroyante — Emphysematous  Gangrene         .        .        .  202 

Diabetic  Gangrene 203 

Dry  Senile  Gangrene 205 

Gangrene  Due  to  Arteriosclerosis  in  Early  Middle  Life — Presenile  Gangrene — Erythro- 

melalgia — Intermittent  Claudication 205 

Gangrene  from  Embolism  and  Thrombosis  of  the  Main  Artery  of  a  Limb        .        .        .  205 

Gangrene  from  Escharotics 208 

The  Effects  of  Cold  upon  the  Tissues 208 

The  Effects  of  Heat 210 

Gangrene  from  Injuries  and  Diseases  of  the  Nervous  System 212 

Trophic  Ulcer 213 

Decubitus  or  Bedsore 213 

Symmetrical  Gangrene — Raynaud's  Disease 214 

Noma,  Cancrum  Oris — Gangrone  of  the  Vulva,  the  Umbilicus 215 

Hospital  Gangrene 216 

Delirium  Tremens 217 

Iodoform  Poisoning 219 

Orthoform  Dermatitis 219 


CONTENTS 


XI 


CHAPTEB 
I  DMORS 
Definition  ano  Classification    .... 
Occurrence       

I  »l  IONOBIS 

The  Diagnosis  of  the  Different  Kinds  of  Tui 
Connective-!  issue  Tumors         .... 

The  Epithelial  Tumors 

Cystic  Tumors 

Teratoma 


PACl 

22 1 
223 
22  1 
227 

_'  _'  i 
252 
262 

_'71 


CHAPTER    VIII 
i  r  ictures  and  disi.oca  i  ions 

Fractures 

Causation  of  Fractures       .... 

The  Varieties  of  Fracture  . 

The  Objective  Signs  of  Fracture 

Subjective  Symptoms        .... 

Complications  and  Course  of  Fractures 
Dislocations 


272 
272 
274 
277 
285 
286 
294 


CHAPTER   IX 
SYPHILIS   AND    LEPROSY 


Syphilis 
Leprosy 


303 
326 


CHAPTER   X 
DISEASES   OF   THE    BLOOD-VESSELS 


Aneurism 

\i;  iki;io-venous  Aneurism 
Inflammation  of  the  Blood-vessels 


329 
332 
334 


CHAPTER    XI 
THE    X   RAYS   IN    SURGICAL   DIAGNOSIS 

I. — The  X-ray  Apparatus 339 

Current :;:'''-' 

Apparatus •  339 

II.— Technic ;'s 

The  General  Technic  of  Radiography :;'s 

(a)  The  Fluoroscope 358 

(b)  The  Making  of  X-ray  Pictures  and  the  Development  of  the  Photographic  Plate 

(c)  Stereoscopic  Radiography 360 

III. — The  Diagnostic  Value  of  the  X-hus  in  Injuries  and  Disi  uses  '-'^u 

(<i)  Fractures,  Dislocations,  and  Deformities  of  Bone :;,,~ 

(6)  X-ray  Diagnosis  of  Diseases  of  Hone 370 

(c)  The  Detection  and  Location  of  Foreign  Bodies  by  Means  of  the  X-rays 

(d)  The  Recognition  of  Tumors  and  Diseases  of  the  Sofl  Parts  by  Mean-  of  the  X-rays  374 
[•  )  The    Detection    of    Pathological    Concretions-  Stone  in   the    Kidney.    Inter.    Uri- 
nary Bladder,  and  Biliary  Calculi •'"  ( 

(/)  The   Injuries   Produced  l>y  the  Diagnostic  Use  of  the  X-rays  upon  Patients  and 

upon  X-ray  Operators 381 


Xll 


CONTENTS 


CHAPTER  XII 

INJURIES   AND    DISEASES   OF   THE   SCALP 

PAGE 

Subcutaneous  Wounds  of  the  Scalp 386 

Open  Wounds  of  the  Scalp 389 

Diseases  of  the  Scalp 394 

Tumors  of  the  Scalp 400 

CHAPTER   XIII 

INJURIES   AND    DISEASES   OF   THE   SKULL 

Diagnosis  of  Injuries  of  the  Skull ' 405 

Diseases  of  the  Skull 412 


CHAPTER   XIV 
THE   INJURIES   AND   DISEASES   OF   THE   BRAIN   AND   ITS   MEMBRANES 

General  Considerations 

Cerebral  Localization 

Cranio-cerebral  Topography 
Injuries  of  the  Brain  . 
The  Diseases  of  the  Brain 
Injuries  and  Diseases  of  the  Frontal  Sinus 


417 

417 
421 
424 
433 
443 


CHAPTER   XV 

INJURIES   AND   DISEASES   OF   THE   FACE 

Congenital  Defects 445 

Injuries  of  the  Face 447 

Diseases  of  the  Face 449 

Tumors  of  the  Face -453 

Injuries  and  Diseases  of  the  Orbit 460 

Affections  of  the  Fifth  and  Seventh  Pairs  of  Cranl\l  Nerves         ....  461 

Injuries  and  Diseases  of  the  Nose 463 

The  Jaws -470 


CHAPTER   XVI 

INJURIES   AND    DISEASES   OF   THE   MOUTH   AND   THROAT 

Diseases  of  the  Mucous  Membrane  of  the  Mouth 483 

The  Tongue 484 

The  Palate,  Tonsils,  and  Pharynx 490 


CHAPTER   XVII 

INJURIES  AND   DISEASES   OF   THE   EAR 

The  External  Ear 501 

Tympanic  Membrane 504 

Examination  of  the  Ear 506 

The  Middle  Ear 512 


CON  I  I 


Xlll 


CHAPTER    Will 
[NJURIE8    \M>    DI8J   \-i  .s   01     Mil.    SALIVARY    GLANDS 


Injuries  oi    rHE  Sauvari   Glands 
Diseases  oi    rHE  Bauvari   Glands 

Tl  MORS   0J     i  in.    SaLI\  AR1    <  rLANDS 


."Is 

519 

52 » 


CHAPTER    XIX 
THE   NECK 
Congenital  Defects  of  the  Neck     .... 

In.h  eues  "i    i he  Neck 

Subcutaneous  Injuries  of  the  Neck  .... 

\\  ouads  of  the  Neck  

Inflammatory   Processes  oi    rHE  Neck 

Ami  EUSMS    I  'I     THE    NECK 

Ti  mors  of  i  he  Neck 

|)i-i  \-i is   \\i)  Tumors  of  the  Thyroid  Gland 
The  I.aki  nx  and  Trachea 


CHAPTER    XX 
THE    ESOPHA'.I  S 

Topography  of  the  Esophagus 

R.ELA  nONS   OF   THE    EsOPB  UJU8 

Methods  of  Examining  thk  Esophagus    . 
Congenital  Defects  of  the  Esophagus  . 

Injuries  of  the  Esophagus 

Ruptures  and  Perforations  of  the  Esophagi  - 

FoKKIUN     BoDIKS    IN    THK     Est  >1'H  \t  iUS       .... 

Diseases  of  the  Esophagus 


CHAPTER   XXI 

THE   THORAX 
Deformities  of  the  Thorax 

Congenital  Deformities  of  the  Thorax 

Acquired  Deformities  of  the  Thorax 
Injuries  of  thk  Thorax  and  Its  Contents 

Subcutaneous  Injuries 

Wounds  of  the  Thorax 

Fractures  and  Dislocations 
Diseases  of  the  Thoracic  Wall 
I  »i-i  ^.ses  of  thk  Pleura 
i  > i — t  \-i  -  or  thk  Lung   . 
Tin    Mediastinum 
Aneurism  ok  the  Aorta 
Diseases  of  the  Pericardium 


CHAPTER    XXII 

in i :  BR1  \-i 

Anatomical   lnd  Physiologicai   Considerations  {Partly  adapted  from  Merkd) 

Congenital  Anomalies  <>k  thk  Breast 

Injuries  of  thk  Breast 

Diseases  ok  the  Breast 

Tumors  of  the  Breast 


xiv  CONTENTS 

CHAPTER  XXIII 

THE   ABDOMEN  „.„„ 

PAGE 

Injuries  of  the  Abdominal  Wall 692 

Diseases  of  the  Abdominal  Wall 695 

Diseases  of  the  Umbilicus 701 

CHAPTER   XXIV 

THE   PERITONEUM 

Peritonitis 709 

Injuries  of  the  Peritoneum  and  Abdominal  Contents 732 

CHAPTER   XXV 

INJURIES   OF   SPECIAL   ABDOMINAL    ORGANS 

Injuries  of  Special  Abdominal  Organs 743 

INDEX 773 


LIST  OF  ILLUSTRATIONS 


Colored  Plate. — Diagrams  illustrating  the  more  definitely  localized  of  the  cortical 
centers  of  the  exposed  parts  of  the  hemispheres        ....     Facing  pagt 


120 


1, — Diagram  to  illustrate  the  general  arrangement  of  teeth  in  poisonous  and  nonpoison- 

OUS snakes  ......... 

2. — Gunshol  fracture  of  radius 

3,  a  and  6. — Fracture  of  the  astragalus 

•I,  «  and  l>. — Gunshot  fracture  of  the  upper  end  of  the  radius 

5. — Photograph  of  the  head  of  a  male  cadaver,  showing  wounds  of  entrance  in  tl 

C). — Photograph  Bhowing  the  wounds  of  entrance  <>t'  two  pistol  bullets 

7. — Photograph  of  two  shots  to  illustrate  the  difference  in  the  effects  upon  the  skin  of 

black  and  smokeless  powders 

8. — Gunshol  wound  of  the  temporal  region,  suicidal 

'.). — Effects  upon  the  body  of  a  shotgun  loaded  with  birdshol  and  fired  at  close 

10. — Photograph  of  shot  No.  -  and  shot  Xo.  4  described  in  text 

11. — Hemoglobinometer 

12. — Hematocytometer 

13. — Blood-counting  chambers 

14. — Carbuncle  of  the  back 

15. — Trocar  and  cannula 

16. — Potain's  aspirator 

17. — Dieulafoy's  aspirator 

18. — Temperature  chart  of  a  case  of  aseptic  wound  fever 

19. — Temperature  chart  of  a  case  of  sapremia     .... 

20. — Thatcher  mosquito 

21. — Chart  of  a  case  of  mixed  sapremic  and  pyogenic  infection 

22. — Sondern's  table  of  differentia]  leucocyte  counts 

23. — Tuberculosis  of  the  lymph  nodes  of  the  neck 

24. — Tuberculosis  of  the  cervical  lymph  nodes,  marked  periglandular  infiltration 

2.5. — Bodgkin's  disease 

26. — Tuberculosis  of  the  first  phalanx  of  index  finger,  with  sinuses 

27. — X-ray  picture  of  early  tuberculosis  of  the  elbow  in  a  child 

28. — Tubercular  arthritis  of  the  knee-joint 

29.     Tubercular  cold  abscess  of  the  back  secondary  to  tuberculosis  of  a  rib 

30. —  Primary  synovial  tuberculosis  of  the  knee  joint,  enormous  tuberculous  h 

31. — Tubercular  abscess  of  thigh  about  to  rupture 

32. — Extreme  contracture  of  both  knee-joints  from  quiescent   tubercular  arthriii- 

33. — Syphilitic  productive  inflammation  of  the  tibia  with  meat  thickening  of  the  shaft 

34. — Syphilitic  necrosis  with  destruction  of  the  nasal  bones 

35. — Charcot's  elbow  in  a  case  of  tabes  dorsalis 

36. — Charcot's  knee-joint 

37. — Arthritis  deformans  of  the  joints  of  the  fingers  in  an  old  woman     .... 


ydrops 


l:; 

_'l 
25 
26 
36 

39 

4d 
44 
45 


84 

84 

sl 

'.'ii 
'.'I 
in:; 
153 
154 
1 55 
157 
158 
lf.il 
162 
P.  : 
164 
165 
166 
166 
167 
168 
169 


xvi  LIST   OF  ILLUSTEATIONS 

FIG.  PAGE 

38. — Arthritis  deformans  of  the  knees 170 

39. — Arthritis  deformans  of  the  joints  of  the  toes 171 

40. — Circumscribed  chronic  osteomyelitis  of  the  tibia,  showing  sinus  leading  to  dead  bone .  184 
41. — X-ray  of  case  shown  in  Fig.  40,  showing  thickening  of  shaft  of  the  bone  from  chronic 

inflammation  and  cavity  in  the  shaft  containing  a  small  sequestrum     .        .        .185 

42. — Syphilitic  periostitis  of  the  shafts  of  the  radius  and  ulna 190 

43. — Productive  syphilitic  osteitis  of  ulna 191 

44. — Gummatous  inflammation  of  the  frontal  bone  with  perforation  of  the  skull          .        .  192 

45  and  46. — Photographs  of  a  case  of  achondroplasia  congenita 194 

47. — A  marked  condition  of  bow-legs  (genu  varum) 195 

48. — A  marked  condition  of  knock-knee  associated  with  rachitis 195 

49. — Case  of  acromegaly 196 

50  and  51. — Brain  of  patient  in  case  shown  in  Fig.  49 197 

52. — Dry  gangrene  of  the  foot 200 

53. — Diabetic  gangrene  of  the  foot  following  Pott's  fracture     . 204 

54. — Moist  gangrene  of  the  foot  from  diabetes 206 

55. — Carbolic  acid  gangrene  of  a  finger 208 

56.— Cicatricial  contraction  following  extensive  burn  of  the  upper  extremity  with  com- 
plete loss  of  function 209 

57. — Extensive  scarring  and  deformity  of  the  arm  following  a  burn 210 

58. — Deformity  of  face  and  neck  two  years  after  a  severe  burn 211 

59. — Deformity  of  foot  and  ankle  following  severe  burns 213 

60. — Extensive  bed-sore  of  the  sacral  region  from  Caisson  disease 214 

61. — Noma,  gangrene  of  the  vulva  in  a  little  girl 216 

62. — Fibro-lipoma  of  the  buttock 227 

63.— Lipoma  of  the  shoulder 228 

64^ — Multiple  lipomata  of  the  back  of  the  neck 228 

65. — Fibroma  molluscum 229 

66. — Soft  fibroma  of  buttock  and  thigh 230 

67. — Hard  fibroma  of  the  lobule  of  the  ear  (keloid) 231 

68. — Fibroma  growing  in  the  soft  parts  over  the  knee  joint      .       ' 232 

69. — Lipoma  in  the  popliteal  space        .                                233 

70. — Cavernous  angioma,  congenital 236 

71. — Mixed  venous  and  lymphangioma         . 237 

72. — Submucous  fibro-myoma  of  the  uterus 239 

73. — Multiple  fibro-myomata  of  the  uterus 240 

74. — Fibro-myoma  of  the  uterus  with  double  hemato-salpinx 240 

75. — Recurrent  lympho-sarcoma  with  multiple  localizations  (Hodgkin's  disease)          .        .  241 

76. — Diffuse  fibro-lymphangioma  of  lower  extremity  (nonparasitic  elephantiasis)         .        .  242 

77. — Ulcerated  and  inoperable  sarcoma  of  ribs,  pleura,  and  pericardium        ....  243 

78. — Sarcoma  of  the  shoulder-blade 244 

79. — Multiple  sarcomatous  nodules  in  the  skin  of  the  trunk 245 

80. — Recurrent  sarcoma  of  the  back 246 

81. — Recurrent  sarcoma  of  the  shoulder 247 

82. — Sarcoma  of  the  skin  on  the  inner  aspect  of  the  knee-joint,  ulcerated     ....  24S 

83. — Sarcoma  of  great  toe 248 

84. — Mediastinal  lympho-sarcoma          .        .        .        .                 249 

85. — Recurrent  sarcoma  of  upper  jaw  and  orbit 250 

86. — Sarcoma  of  the  vulva 251 

87. — Very  extensive  soft  papillomata  of  the  penis 253 

88. — Adenoma  of  the  breast 255 

89.— Rodent  ulcer 257 

90. — Epithelioma  of  the  ankle  growing  upon  an  old  ulcer 258 

91. — Epithelioma  on  the  dorsum  of  the  hand  which  grew  in  an  old  scar        .        .        •        •  258 


LIST    OF    JU. I  >'l  RATK 


xvn 


i  10 

92.  Epithelioma  developing  in  the  scar  of  an  amputation  stump 

93.  Epithelioma  <>f  the  lower  lip 

94.  Scirrhous  carcinoma  of  the  breaal 

95.  Carcinoma  simplex  of  the  breast,  ulcerated 

96  Carcinoma  of  the  femur  and  knee  secondary  to  carcinoma  <>t"  the  uterus 

!i7.  Sebaceous  cyst  -  of  the  scalp 

Rare  congenital  cysts  of  the  buttock    ... 

Sebaceous  cyst  of  the  back  of  <  li<-  neck,  infected 

100.     I  Jystic  tumor  of  the  palmar  Burfai t"  tin-  middle  finger  following  an  injury 

101. — Cystic  dilatation  of  both  prepatellar  bursas 

102.  Cystic  dilatation  of  I •< > 1 1 »  prepatellar  bursa;  ami  of  I »« > 1 1 1  olecranon  bursa 

103.  Deformity  in  recent  fracture  of  radius  and  ulna  in  the  lower  third  of  the  (bream 
in  l.     i)i,|.  very  oblique  fracture  of  the  shaft  of  the  femur 

105.  Fracture  of  the  lower  end  of  the  radius       .... 

106.  Fracture  of  the  radius  ami  ulna 

107.  Fracture  of  the  olecranon  process  of  the  ulna  with  Beparatioi 

|us  Fracture  of  the  tibia  and  fibula 

109,  <  > I » 1  Fracture  of  the  patella,  separation  of  tin-  fragments 

llit.  Fracture  of  the  shaft  of  the  femur 

111.  Fracture  of  the  shaft  of  the  humerus  in  a  child 

112.  Fracture  of  the  tibia  and  fibula 

113. — Fracture  of  the  tibia  and  fibula 

1 1  1.      Fracture  ef  the  femur 

115.— Fracture  of  the  radius  ami  ulna 

HO.-  Spirochetes 

117. — Ulcerated  initial  lesion  of  syphilis 

US. — Chancre  of  the  chin 

119. — Chancre  of  the  lower  lip 

120. — Chancre  of  the  finger 

121. — Maculo-papular  (polymorphous)  syphilid     .... 

122. — Papular  syphilid 

123. — Squamous  syphilid  of  palm 

Pit.      Fissured  and  ulcerated  eczema  of  palm,  simulating  an  ulcerating  syph 

125. — Tubercular  syphilid  of  the  buttocks 

126.— Ulcerated  gumma  of  the  breast 

127. — Syphilitic  arthritis  of  the  elbow 

12S.      Aneurism  of  the  common  femoral  artery  in  Scarpa's  triangle 

120. — Varicose  veins  of  the  leg 

130.     Dr.  Sweet's  localizing  apparatus 

131. — Side  view  of  Dr.  Sweet's  localizing  apparatus 

1.32. — Side  view  of  indicating  apparatus 

133. — Author's  X-ray  table  for  taking  stereoscopic  radiographs 
134. — Diagram  illustrating  tin-  arterial  supply  of  the  face  and  seal] 

135.  Tuberculous  abscess  of  the  scalp 

136.  Cirsoid  aneurism  of  the  scalp  and  skull       .... 
[37.   -Unusually  large  sebaceous  cysts  of  the  scalp 

138.  Fibro-lipo-lymphangioma  of  the  scalp,  neck,  and  shoulders 

139.  —Result  after  operations  upon  case  shown  in  Fig.  138 

1  10.      Angioma  of  tin'  scalp 

141.-    Abscess  of  the  scalp  behind  the  ear.  simulating  mastoiditis 

1  12.     simple  depressed  fracture  of  the  skull  without  symptoms 

143. — Depressed  fracture  of  the  skull 

144. — Diffuse  hypertrophy  of  the  skull  

14"). — Ulcerated  sarcoma  of  the  skull 


xviii  LIST    OF   ILLUSTRATIONS 

FIG.  PAGE 

146. — Brain  of  gorilla,  showing  excito-motor  area  as  delineated  by  cortical  faradization       .  418 
147,  a  and  b. — Diagram  showing  the  relations  of  the  more  important  fissures  and  convolu- 
tions to  the  sutures  and  bony  landmarks  of  the  skull 419 

148. — Kronlein's  craniometer ( 423 

149. — Diagram  of  lines  and  angles  constructed  upon  the  skull  for  the  location  of  the  convo- 
lutions and  fissures 424 

150. — Chipault's  method  of  cranio-cerebral  localization  by  angles  and  measurements   .        .  425 

151. — Fungus  cerebri  following  an  operation  for  compound  depressed  fracture  of  the  skull  430 

152. — Abscess  of  the  cerebral  cortex 434 

153. — Echinococcus  cyst  of  the  brain 437 

154  and  155. — Meningocele 441 

156. — Double  harelip  in  an  infant 445 

157. — Single  harelip  in  an  adult 445 

158. — Harelip  and  cleft  palate  in  an  adult 446 

159. — Scars  and  deformity  following  extensive  burns  of  the  face 448 

160. — Noma,  gangrene  of  the  cheeks  and  lips 451 

161,  a  and  b. — Dermoid  cyst  of  the  septum  of  the  nose 452 

162. — Congenital  mixed  lymph  and  venous  angioma  of  the  face 453 

163.— Cavernous  lymphangioma  of  the  face,  congenital 454 

164. — Congenital  lymphangioma  of  the  upper  lip  (macrocheilia) 454 

165. — Congenital  angioma  of  the  ear 456 

166. — Rapidly  growing  and  malignant  form  of  epithelioma  of  the  cheek          ....  456 

167. — Early  stage  of  epithelioma  of  the  lip 457 

168,  a  and  b. — Epithelioma  of  the  lower  lip 458 

169. — Epithelioma  of  the  lower  lip 459 

170. — Slight  facial  paralysis  following  operation  for  mastoiditis 462 

171. — Syphilitic  necrosis  of  the  nasal  bones  ("saddle-nose"  deformity) 464 

172. — Periostitis  of  the  lower  jaw  with  abscess  of  the  cheek 474 

173. — Enormous  mixed  tumor  growing  from  the  body  of  the  lower  jaw  of  a  generally  benign 

character 478 

174. — Giant-celled  sarcoma  of  the  upper  jaw 479 

175. — Front  view  of  the  preceding  case  of  giant-celled  sarcoma 480 

176. — Tuberculous  osteomyelitis  of  the  lower  jaw  in  a  boy 481 

177. — Congenital  deformity  of  the  ear 501 

178. — Boxer's  enchondroma  (fighter's  ear) 502 

179. — Gruber's  aural  speculum 506 

180. — Politzer's  hard-rubber  aural  speculum 506 

181. — Politzer's  air-bag 511 

182. — Sarcoma  of  the  parotid  gland         . 524 

183. — Mixed  tumor  of  the  parotid  gland 525 

184. — Mixed  tumor  of  the  parotid  gland 525 

185. — Mixed  tumor  of  the  parotid  gland 526 

186. — Sarcoma  of  the  parotid  gland r 527 

187. — Photograph  of  patient  shown  in  Fig.  186  taken  soon  after  the  operation,  showing  scar 

and  facial  paralysis 527 

188. — Cyst  developed  in  a  persistent  thyroglossal  duct 530 

189. — Wry-neck  of  congenital  origin 532 

190. — Congenital  wry-neck 532 

191. — Horizontal  section  of  the  neck  at  the  level  of  the  uppermost  ring  of  the  trachea, 

showing  the  facial  layers  of  the  neck 544 

192. — Acute  abscess  in  the  submaxillary  region 547 

193. — Tuberculous  lymph  nodes  of  the  neck,  showing  periglandular  infiltration     .        .        .  552 

194. — Tuberculous  lymph  nodes 553 

195. — Tuberculosis  of  the  lymph  nodes  of  the  neck      .        . 554 


LIST    <)!•    tLLUSTRATIONS  xix 

no,  PAGE 

196.     Inoperable  sarcoma  originating  in  the  lymph  nodes  of  the  neck 557 

197.— Sarcoma  of  the  neck 561 

198.  Branchiogenetic  cyst  of  the  neck  arising  from  the  second  clef  1 .">»;:; 

199.  Multiple  lipomata  of  the  neck 565 

■j(M).     Superficial  lipoma  of  the  neck 566 

201.  Lipoma  of  the  neck  deeply  placed  beneath  the  sternomastoid  muscle           .  567 

202.  Lipoma  of  the  supraclavicular  r<-Lri< hi :,r,7 

203.  Malignanl  type  of  epithelioma  of  the  neck 

204.  Exophthalmic  goiter 

205.  Parenchymatous  goiter :,~:; 

206.  Parenchymatous  goiter :,!.; 

207. — Cystic  goiter  of  rather  large  size :,~:> 

208. — Cystic  goiter 576 

209.  Cystic  goiter .".77 

210.  Bronchoscope 585 

211. — Instruments  to  be  used  with  the  bronchoscope  for  the  extracting  of  foreign  bodies 

from  the  bronchi  and  trachea ;,s.", 

212. — Coin-catcher  and  sponge  probang  Eor  extracting  foreign  bodies  from  the  esophagus  596 

213. — Spring  forceps  for  seizing  foreign  bodies  in  the  esophagus 7 

214. — Graduated  bulbous  bougies  for  detecting  strictures  of  the  esophagus  ....  597 
215. — Esophagoscope  with  small  electric  light  near  its  lower  extremity  for  examining  the 

esophagus  by  direct  vision 600 

216. — X-ray  picture  of  the  thorax  and  neck  of  a  boy  aged  ten,  who  swallowed  a  fifty-cent 

silver  piece 601 

217. — Congenital  atresia  of  the  esophagus 602 

•Jls.   -Anterior  view  of  specimen  in  Fig.  217 602 

219. — Posterior  view  of  specimen  in  Fig.  217 603 

220. — X-ray  picture  of  bullet  wound  of  the  esophagus <i()4 

221.— Esophageal  fistula GOG 

■ill.     Esophageal  fistula 607 

223.      X-ray  picture  of  a  tin  whistle  impacted  in  the  esophagus  of  a  boy  aged  six         .        .  609 

224. — Cancer  of  the  esophagus,  showing  dilatation  of  the  gullet  above  the  stricture  615 

225. — Congenital  deformity  of  the  sternum,  showing  marked  funnel-shaped  depression  622 

22G. — Deformity  of  the  thorax  following  empyema 623 

227. — Deformity  of  the  thorax  following  Pott's  disease ('>_':! 

22S. — Deformity  of  the  thorax  from  von  Jaksch's  anemia 624 

229. — Rupture  of  the  diaphragm,  prolapse  of  the  stomach  and  a  portion  of  the  intestine  into 

the  pleural  cavity 626 

230.—  Subcutaneous  emphysema  from  fracture  of  several  ribs;  rupture  of  both  lungs    .  627 

231. — Deformity  of  the  thorax  following  empyema 628 

232. — Showing  the  relations  of  the  lungs  and  of  the  lower  limit  of  the  pleura  to  the  ribs. 

Thorax  viewed  from  in  front 632 

233. — Showing  the  relations  of  the  lungs  and  of  the  lower  limit  of  the  pleura  to  the  ril>s. 

Thorax  viewed  from  behind 632 

234. — Diagram  to  show  the  relations  of  the  lung  and  the  complementary  pleural  space  t<> 

the  chest  wall 637 

235. — Represents  the  maximum   variation   in   the  position  of  the  anterior  borders  of  the 

pleural  sac  with  reference  to  the  sternum  and  ribs 638 

236. — Traumatic  aneurism  of  the  subclavian  artery 642 

237. — Lipoma  of  the  thoracic  wall 652 

238.  Cancer  en  cuirasse  following  carcinoma  of  the  breast        ...               ...  654 

239.  Aneurism  of  the  arch  of  the  aorta ...  tiiiii 

240.  Epithelioma  of  the  nipple  (Paget's  disease  of  the.  nipple)  .  .  672 
241. — Inflammation  of  die  breasl  in  a  boy 673 


xx  LIST    OF   ILLUSTRATIONS 

FIG.  PAGE 

242. — Acute  inflammation  of  the  breast  in  a  nursing  woman  followed  by  abscess  .        .        .  675 

243.- — Fibro-adenoma  of  the  breast  in  a  young  girl 681 

244. — Fibro-adenoma  of  the  breast  of  large  size    .        .        .        .        .      • 682 

245. — Ulcerated  sarcoma  of  the  breast 684 

246. — Ulcerating  and  fungating  sarcoma  of  the  breast 684 

247. — Scirrhous  carcinoma  of  the  breast,  showing  atrophy  of  the  breast  and  retracting  of 

the  nipple 686 

248. — Scirrhous  carcinoma  of  the  breast  extending  upward  and  outward         ....  687 

249. — Ulcerated  adeno-carcinoma  of  the  breast 687 

250. — Adeno-carcinoma  of  the  breast 688 

251. — Carcinoma  simplex  of  the  breast,  showing  rather  massive  tumor  and  retraction  of  the 

nipple 688 

252. — Ulcerated  carcinoma  of  the  breast 689 

253. — Large  abscess  of  the  abdominal  wall  originating  in  the  sheath  of  the  rectus  muscle    .  696 

254. — Sarcoma  of  the  abdominal  wall 699 

255. — Mixed-celled  sarcoma  of  the  abdominal  wall 699 

256. — Tuberculous  peritonitis  with  abundant  serous  exudation  in  a  child        ....  730 

257. — Fifty-cent  silver  piece  in  the  cardiac  portion  of  the  stomach  removed  by  gastrostomy  752 


SURGICAL    DIAGNOSIS 

VOLUME   I 


CHAPTER    T 
WOUNDS 

Wounds — Definition  and  Classification. — A  wound  may  be  defined  as  m  solu- 
tion of  continuity  of  the  tissues  of  the  body  produced  l>v  traumatism,  with  or 
without  ;i  break  in  the  skin  or  mucous  membrane.  When  then-  is  do  break 
in  the  continuity  of  the  surface,  we  speak  of  the  injury  as  a  subcutaneous 
wound,  <>r  contusion.  When  the  skin  or  mucous  membrane  is  broken,  we  speak 
of  such  injuries  as  open  wounds. 

Subcutaneous  Wounds. — While  wounds  of'  either  class  may  be  of  any 
degree  of  severity,  subcutaneous  wounds  possess  this  peculiarity,  namely,  thai 
they  are  not  usually  exposed  to  the  invasion  of  pyogenic  or  other  microbes  from 
without,  as  is  the  case  with  open  wounds,  in  which  the  skin  or  mucous  mem- 
brane is  broken.  Consequently,  in  subcutaneous  injuries,  one  of  the  greatesl 
perils  to  which  the  human  body  is  exposed  is  avoided  almost  completely;  and 
yet,  under  certain  conditions,  subcutaneous  injuries — notably  if  slighl  in  char- 
acter, and  if  they  occur  in  parts  where  the  blood  circulation  is  naturallv  slow — 
do  occasionally  become  infected.  When  wounds  of  this  kind  are  superficial, 
and  involve  a  portion  of  the  thickness  of  the  skin  or  mucous  membrane,  or  if 
the  nutrition  of  the  skin  is  materially  impaired,  they  may  become  infected 
from  the  bacteria  in  or  upon  the  skin  by  continuity  of  structure.  This  IS, 
however,  an  uncommon  occurrence;  and,  although  subcutaneous  injuries  may 
be  accompanied,  as  we  shall  see  later,  by  constitutional  disturbance,  their 
infection  is  comparatively  rare.  If  so  be  that  the  patient  has  a  suppurating 
locus  in  some  other  part  of  the  body,  the  subcutaneous  wound  may  still  heal, 
and    usually  does   heal,   without  difficulty. 

There  is,  nevertheless,  an  infection  which  takes  place  through  the  blood 
in  subcutaneous  injuries,  both  by  pyogenic  and  other  microbes.  A  common 
example  of  this  kind  of  infection   is  the  acute  purulent    infection  of  the  shafts 

of  the  long  bones   in  children    tthe  acute  suppurative  osteomyelitis).     The 

disease  commonly  begins  near  the  ends  of  the  shaft  of  the  bone,  and  quite 
often  follows  some  slight  injury.  The  same  is  true  of  tuberculosis  of  the 
bones.  In  these  eases  we  must  assume  that  the  injury  has  produced  a  place 
of  diminished  resistance,  and  that  the  bacteria  circulating  in  the  blood  have 
found  here  a  favorable  soil  for  their  development.  Such  bacteria,  in  the  case 
2  1 


2  WOUNDS 

of  tuberculosis,  often  originate  in  a  tubercular  lymphatic  gland,  situated  in 
the  mediastinum  or  elsewhere. 

Open  Wounds. — These  may  be  classified  for  purposes  of  description  into 
those  caused  by  blunt  violence,  such  as  blows  with  clubs,  falls,  and  crushing- 
injuries,  known  as  contused  and  lacerated  wounds,  and  wounds  caused  by  sharp 
instruments,  such  as  knives,  swords,  daggers,  and  the  like;  and  these  may  be 
subdivided  into  (1)  those  in  which  the  length  of  the  wound  is  greater  than 
the  depth,  or  relatively  large  compared  with  the  depth — incised  wounds — and 
(2)  wounds  in  which  the  depth  greatly  exceeds  the  size  or  caliber  of  the 
wound  canal — punctured  wounds.  If  some  specific  poison  is  introduced  into 
the  wound  at  the  time  of  its  infliction,  it  is  called  a  poisoned  wound.  Snake 
bites,  insect  stings  and  bites,  and  wounds  from  poisoned  arrows  are  of  this 
class.  Still  another  class  of  wounds  are  produced  by  missiles  fired  from  guns 
and  rifles.  They  partake  both  of  the  character  of  punctured  wounds  and  of 
contused  wounds.  We  may  speak  also  of  simple  and  of  complicated  wounds. 
An  ordinary  cut  involving  the  soft  parts  is  known  as  a  simple  incised  wound. 
If,  however,  a  joint  or  one  of  the  cavities  of  the  body  is  also  wounded,  we 
speak  of  the  wound  as  a  complicated  wound.  In  reference  to  certain  parts 
of  the  body — notably  the  abdomen,  the  thorax,  and  the  skull — we  speak  of  a 
wound  as  penetrating  or  nonpenetrating,  as  the  case  may  be;  or  if  the  wound 
passes  entirely  through  the  wounded  part,  we  speak  of  it  as  a  perforating 
wound. 

A  very  important  distinction  to  be  drawn  in  regard  to  wounds  depends 
upon  whether  they  are  clean  wounds,  such  as  are  made  by  the  surgeon  during 
properly  performed  operations,  or  whether,  on  the  other  hand,  they  are  soiled 
with  foreign  material,  contain  foreign  bodies,  or  are  actually  infected  with 
pyogenic  or  other  microbes.  All  accidental  wounds  are  properly  regarded  as 
possibly  infected  wounds,  and  in  general  are  treated  accordingly.  The  signs 
and  symptoms  belonging  to  all  wounds  which  involve  the  skin  or  mucous 
membrane  are  three:  namely,  gaping,  pain,  and  hemorrhage. 

SUBCUTANEOUS    INJURIES 

Signs  and  Symptoms. — The  signs  and  symptoms  of  subcutaneous  injuries 
vary  greatly  with  the  severity  of  the  violence  applied,  and  with  the  part  of 
the  body  injured.  A  discussion  of  this  topic  will  fall  more  properly  under  the 
head  of  Regional  Surgery.  A  few  only  of  the  characters  of  such  injuries  may 
be  mentioned  here. 

Pain  in  Subcutaneous  Injuries. — Pain  is  a  very  constant  symptom  of  subcu- 
taneous injuries.  It  varies  greatly  with  the  character  of  the  tissues  injured. 
C Ymtusions  of  those  parts  richly  supplied  with  sensitive  nerves  are  very  painful 
injuries ;  for  example,  contusions  of  the  fingers  and  toes,  contusions  of  the 
bone,  of  some  portions  of  the  face,  and  of  some  other  regions.  The  pain  of 
contusions  is  due  in  part  to  the  injury  of  the  nerves,  and  in  part  to  the  pressure 


SUBCUTANEOUS    I  X.I  t'Kl  I  ■>  3 

produced  by  the  1»1 1  poured  oul   from  the  torn  hi l-vessels  upon  the  nerve 

endings  of  the  injured  part.  This  pain,  due  to  the  pressure  oi  effused  blood, 
varies  greatly  In  different  regions  of  the  body,  and  this  depends  partly  upon 
the  nerve  supply  of  the  injured  region  and  partly  upon  the  density  or  laxity 
of  the  tissues.  An  injury  of  the  subcutaneous  tissues  of  the  arm  or  leg  may 
be  accompanied  by  bul  little  pain,  although  the  quantity  <»t"  effused  blood  i- 
considerable ;  the  tissues  arc  lax,  and  the  effused  blood  easily  finds  its  way 
through  the  tissues.  A  contusion,  however,  of  the  end  of  the  finger,  with  the 
effusion  of  a  few  drops  of  blood  only,  between  the  finger  nail  and  its  matrix,  is 

a  very   painful    injury    indeed. 

Effused  Blood  in  Subcutaneous  Injuries. — Certain  special  signs  and  symp- 
toms dwv  to  effused  blood  in  certain  regions  will  be  referred  to  more  especially 
under  the  head  of  Regional  Surgery.     For  example,  ;i  quantity  of  blood  poured 

cut  into  the  interior  of  the  skull  may  produce  serious,  or  even  fatal,  symptoms, 
although  the  amount  of  blood  be  small.  When  blood  is  extravasated  into  the 
subcutaneous  tissues  in  considerable  quantity,  it  forms  a  circumscribed  elastic 
tumor  beneath  the  skin,  giving  signs  of  fluctuation.  If  such  a  tumor  commu- 
nicates with  an  artery  <d"  considerable  size,  it  may  even  pulsate,  ami  may  form 
what  is  known  as  an  aneurism,  or  arterial  hematoma   (see  Aneurism). 

Ecchymoses  in  Subcutaneous  Injuries. — Ordinarily  hi 1  extravasated  be- 
neath the  skin  makes  its  way  rather  rapidly  through  the  meshes  of  the  con- 
nective tissue  in  the  vicinity,  and  is  absorbed  in  from  a  few  days  to  a  few 
weeks,  according  to  the  amount  of  blood  and  the  situation.  Some  of  the  blood 
finds  its  way  to  the  surface,  and  produces  a  characteristic  discoloration  of  the 
skin  (ecchymosis).  The  color  is  at  first  dark  red,  blue,  or  purple,  and  within 
twenty-four  or  forty-eight  hours   the  edge  of  the  ecchymosed    area   becomes 

lighter  in  color  and  of  a  violet  hue,  and  the  discoloration  increases  in  size. 
As  the  days  go  by  the  edge  of  the  discolored  area  becomes  yellow,  while  the 
central  portion  becomes,  first  brown,  then  green,  and   finally  yellow,  this  being 

the  last,  color  to  disappear.  Tn  vascular  regions,  where  absorption  takes  place 
rapidly,  these  color  changes  may  be  passed  through  in  a  few  days.  In  the 
subcutaneous  tissues  of  the  extremities,  however — notably  in  the  leg — the  dis- 
coloration may  last  for  many  weeks.  The  effused  blood  travels  beneath  the 
surface  to  some  extent,  by  gravity;  hence,  an  injury  of  the  shoulder  may  give 
rise  to  ecchymosis  of  the  elbow  and  forearm,  which  may  not  appear  for  several 
days  after  the  injury.  The  different  shades  of  color  are  due  to  gradual  changes 
in,  and  the  absorption  of,  the  pigment  of  the  blood. 

Subcutaneous  Injuries  to  Muscles. — Subcutaneous  injuries  may  be  of  any 
possible  degree  of  severity.  They  may  consist  of  merely  the  rupture  id'  a  few 
minute  blood-vessels  beneath  the  skin,  or  the  fascia  covering  the  muscles  may 
be  ruptured,  sometimes  with  the  production  of  a  hernia  of  the  muscular  belly 
through  the  rent,  to  be  recognized  by  the  formation  of  a  soft  swelling,  noticeable 
chiefly  when  the  muscle  is  put  in  a  state  of  contraction.  Muscular  bellies,  also, 
may   be   torn   completely   or   partly,   and    tendons   ruptured    or   torn    away    from 


4  WOUNDS 

their  attachments  to  the  hone.  If  a  muscle  of  considerable  size  is  ruptured, 
a  cavity  or  hiatus  may  he  very  distinctly  felt  hy  passing  the  fingers  along  the 
limb  and  making  gentle  pressure.  When  the  site  of  the  rupture  in  the  muscle 
is  reached,  some  tenderness  will  he  complained  of,  and  the  fingers  of  the 
examining  hand  will  sink  more  or  less  deeply  into  the  gap.  Loss  of  function 
of  the  muscle,  or  weakness,  may  also  be  demonstrated,  and  that  portion  of 
the  muscle  which  still  contracts  under  the  control  of  the  will  may  form  a 
visible  and  palpable  tumor. 

Subcutaneous  Injuries  to  Tendons. — If  a  tendon  is  ruptured  or  torn  from 
its  bony  insertion,  the  formation  of  a  tumor  will  usually  be  observed  when  the 
muscle  contracts,  and  in  case  the  tendon  is  the  sole  insertion  of  the  muscle, 
loss  of  function  will  be  complete  in  that  muscle.  Such  ruptures  may  occur 
from  direct  violence,  or  from  a  violent  contraction  of  the  muscle  itself.  The 
ligamentum  patella?,  the  biceps  tendon  of  the  arm,  and  occasionally  other 
tendons  are  torn  in  this  way. 

Subcutaneous  Injuries  to  Nerves. — These  may  be  of  the  nature  of  contusions, 
more  or  less  severe,  or  of  actual  crushing  and  total  destruction  of  nerves,  or 
of  ruptures  of  the  nerve  fibers,  with  or  without  simultaneous  rupture  of  the 
nerve  sheath.  Dislocation  of  certain  nerves — notably  of  the  ulnar  nerve  where 
it  passes  behind  the  internal  condyle  of  the  humerus  at  the  elbow — have  occa- 
sionally been  recorded.  Such  dislocation  may  occur  from  direct  or  from  mus- 
cular violence,  and  the  dislocated  nerve  may  sometimes  be  felt  as  a  tender 
cord  beneath  the  skin.  The  symptoms  of  contusions  of  nerves  vary  with  the 
severity  of  the  injury.  If  the  nerve  has  been  merely  bruised  and  not  actually 
destroyed,  the  immediate  symptoms  will  be  a  feeling  of  numbness,  sometimes 
also  of  heat,  in  the  parts  supplied  by  the  nerve.  Tingling  and  prickling  sensa- 
tions will  also  be  felt.  Later  there  may  be  anesthesia,  hyperesthesia,  and  paral- 
ysis, sometimes  muscular  spasms  and  disturbances  of  nutrition  in  the  part 
which  the  nerve  supplies.  If  the  nerve  fibers  are  actually  destroyed,  atrophy 
of  the  muscles  supplied  by  the  nerve  follows  with  reaction  of  degeneration. 

The  motor  symptoms  are  more  marked  than  the  sensory.  This  is  explained 
by  some  observers  on  the  ground  that  the  sensory  nerves  anastomose  more 
freely  than  do  the  motor  nerves,  and  by  others  on  the  ground  that  a  more 
perfect  conducting  power  is  necessary  to  conduct  motor  influences  (see  also 
Neuritis).  The  degree  of  destruction  to  which  a  nerve  trunk  has  been  sub- 
jected cannot  always  be  recognized  at  once  when  the  injury  is  subcutaneous. 
If  some  sensation  remains,  and  not  all  the  muscles  supplied  by  the  nerve  are 
paralyzed,  the  nerve  has  not  been  completely  destroyed,  and  the  prognosis  is 
not  unfavorable.  If,  on  the  other  hand,  the  parts  supplied  by  the  nerve  are 
entirely  painless  and  insensitive,  and  if  complete  paralysis  of  the  muscles 
supplied  by  the  nerve  is  present,  and  if  rapid  and  complete  wasting  of  the 
muscles  occurs,  the  nerve  is  destroyed.  (The  Injuries  of  Special  Nerves  will 
be  spoken  of  under  Regional  Surgery.  Injuries  of  Bones  and  Joints  will  be 
spoken  of  under  separate  headings.) 


CONTUSED  A.\l>  LACERATED  WOUNDS  5 

CONTUSED  AND  LACERATED  WOUNDS 

Contused  and  lacerated  wounds  occur,  as  already  stated,  from  the  effects 
of  lihini  violence.  They  are  interesting  to  the  surgeon  from  a  diagnostic  point 
of  view  for  a  number  of  reasons.  These  wounds,  from  the  manner  of  their 
infliction  and  from  the  diminished  vitality  of  the  tissues,  are  frequently  in- 
fected. The  infected  material  is  frequently  so  pressed  into  the  tissues  al  the 
time  the  injury  is  received  thai  it  is  impossible  entirely  to  remove  it.  The 
contusion  and  laceration  of  the  (issues  is  such  that  the  vitality  of  the  injured 
pari  may  be  impaired  or  lost  over  an  area  large  <>r  Bmall.  The  integrity  of  an 
entire  limb  (or  the  life  of  the  individual)  may  be  endangered.  The  intelligenl 
care  of  injuries  of  this  class  demands  a  high  degree  of  skill  and  judgmenl  on 
the  pari  of  the  surgeon. 

Character  of  Contused  and  Lacerated  Wounds. — In  the  examination  of  con- 
tused :in<l  lacerated  wounds,  n  number  of  questions  will  arise  for  solution. 
Some  of  these  will  he  considered  here,  and  some  may  more  properly  be  spoken 
of  under  Regional  Surgery.  In  the  first  place,  the  surgeon  will  remember  that, 
in  the  examination  of  these  wounds,  the  same  technic  musl  be  carried  ou1  as 
accompanies  any  aseptic  surgical  operation.  No  wound,  fresh  or  old,  i-  so 
dirty  or  so  infected  but  that  further  infection  is  possible.  In  contused  and 
lacerated  wounds  there  is  added  the  necessity  of  removing,  as  far  as  may  be, 
foreign  bodies  and  infected  materials  introduced  at  the  time  of  the  injury 
or  later.  It  is  astonishing  how  much  may  be  accomplished  in  this  direction 
if  only  sufficient  care  and  pains  be  taken.  In  these  wounds  it  often  happens 
that  the  wound  of  the  skin  is  comparatively  small,  while  the  stripping  of  the 
skin  from  the  deeper  parts  and  the  injury  to  the  deeper  structures  is  extensive. 
In  such  cases  the  skin  wound  may  he  enlarged  to  a  sufficient  extent  to  permit 
free  inspection  of  the  deeper  structures;  the  skin  incision  should  be  made  in 
such  position  and  direction  that  the  blood  supply  of  the  skin  will  be  preserved 
as  far  as  may  be. 

To  determine  to  what  extent  the  vitality  of  the  skin  has  been  destroyed  by 
the  injury  in  recent  cases  is  not  always  easy.  The  surgeon  may  he  assisted 
in  his  judgment  by  certain  simple  observations.  Tn  some  regions  of  the  body 
the  skin  and  suhcutancous  tissues  have  an  extraordinary  vitality.  Aur  to  their 
abundant  blood  supply.  The  seal]),  the  face,  the  tongue,  the  scrotum,  the  penis, 
the  palm  of  the  hand,  and  fingers  and  toes,  are  notably  well  supplied  with 
blood;  and  a  degree  of  contusion  ami  laceration  which  would  lead  to  necrosis 
in  other  regions  may  be,  and  often  is,  recovered  from  in  these  parts.  If  flaps 
of  skin  and  subcutaneous  tissue  are  stripped  up,  their  survival  is  rendered  more 
probable  if  the  blood  supply  runs  into  the  base  of  the  (lap  rather  than  in  the 
opposite  direction.  If  the  skin  is  extensively  stripped  up,  and  at  the  same 
time  separated  from  the  subcutaneous  /issues,  this  indicates  that  tin1  blood 
supply  of  such  skin  is  probably  destroyed,  anil  that  such  a  tlap  of  skin  will 
probably  become  necrotic,  either  wholly  or  in  part.     Skin  and  subcutaneous 


6  WOUNDS 

tissues  which  are  frayed  out  and  shredded  into  a  fibrous  fringe,  are  unques- 
tionably dead. 

The  vitality  of  tendons  is  remarkable,  although  their  blood  supply  is  small. 
If  they  can  be  covered  by  living  healthy  tissues  and  their  continuity  is  not 
destroyed,  it  may  generally  be  assumed  that  they  will  live,  and  that  their 
function  will  be  more  or  less  perfectly  preserved.  Muscular  tissue  which  is 
pulpified  will  usually  not  survive ;  but  if  sound  muscular  tissue  exist  above 
and  below  the  point  of  injury,  and  the  nerve  supply  of  the  muscle  is  intact,  a 
fibrous  splice  may  take  the  place  of  the  divided  muscle,  or  union  by  suture 
may  result  in  a  useful  muscle.  As  has  been  stated  under  the  head  of  Subcu- 
taneous Injuries,  a  nerve  trunk  may  be  contused  with  only  temporary  disability, 
or  its  nerve  fibers  may  be  destroyed  with  preservation  of  the  fibrous  sheath. 
The  diagnostic  conclusions  to  be  drawn  from  the  mere  appearance  of  such  a 
nerve  in  a  recent  wound  are  not  definite,  unless  the  nerve  trunk  be  actually 
severed,  when  it  is  certain  that  motor  and  sensory  paralysis  will  result,  and 
be  permanent,  unless  the  divided  ends  are  united  by  suture. 

Injuries  of  the  Blood  Vessels  in  Contused  and  Lacerated  Wounds. — Such  in- 
juries are  of  the  greatest  diagnostic  and  prognostic  importance.  While  such 
wounds  may  bleed  freely  and  even  fatally,  the  hemorrhage  is  generally  far 
less  than  is  the  case  with  incised  wounds.  The  vessels  are  often  torn  across 
or  crushed  in  such  a  manner  that  the  coats  of  the  arteries  become  twisted,  con- 
tracted, and  retracted,  and  in  many  instances  the  ends  of  the  torn  vessels  are 
either  wholly  or  partly  closed,  and  bleeding  is  slight  or  absent,  I  have  seen 
several  instances  in  which  the  entire  upper  extremity  had  been  torn  off  by 
machinery,  or  crushed  off  by  the  wheels  of  a  railway  carriage,  and  no  bleeding 
has  occurred  from  the  axillary  artery.  The  end  of  the  vessel  could  be  plainly 
seen  in  the  wound,  either  pulled  out  into  a  solid  cord  or  twisted  in  such  a 
manner  that  no  blood  escaped. 

In  the  examination  of  such  wounds,  if  superficial  and  of  moderate  extent, 
the  source  of  bleeding,  if  such  exist,  is  usually  easily  seen,  whether  from  arte- 
ries or  veins.  If  the  injury  involves  the  cranial  cavity  or  thorax  or  abdomen, 
special  diagnostic  signs  and  symptoms  exist  which  will  be  discussed  under 
Regional  Surgery.  In  injuries  of  the  extremities,  if  extensive,  the  condition 
of  the  main  artery  of  the  limb,  and  consequently  of  the  nutrition  of  the 
extremity,  may  generally  be  inferred  by  finding  pulsation  in  the  radial  and 
ulnar  artery  at  the  wrist,  or  the  dorsalis  pedis  and  posterior  tibial  at  the  ankle, 
as  the  case  may  be.  If  such  pulsation  is  present,  the  limb  will  probably  retain 
its  vitality,  if  infection  can  be  avoided.  Absence  of  such  pulsation,  together 
with  coldness  of  the  fingers  or  toes  and  paleness  of  the  hand  or  foot,  indicates 
serious  impairment  of  nutrition.  Destruction  of  both  the  main  artery  and 
vein  of  the  limb  is  of  most  serious  import.  Destruction  of  the  artery  alone 
is  less  so,  and  destruction  of  the  axillary  or  femoral  vein,  with  preservation 
of  the  artery,  are  still  less  threatening;  but  any  one  of  these  conditions  may 
involve  partial  or  complete  loss  of  nutrition  of  the  limb. 


CONTUSED  AND  LACERATED  WOUNDS  7 

An  observation  made  when  I  was  interne  in  Bellevue  Hospital  is  suggestive 
and  instructive.  A  large,  well-nourished  man,  thirty-eighl  years  of  age,  was 
broughl  to  the  hospital  suffering  from  ;i  severe  contused  and  lacerated  wound 
involving  the  sofi  tissues  above  and  below  the  right  elbow-joint.  On  the 
anterior  aspect  the  skin  was  extensively  stripped  up  from  the  deeper  tissues 
along  the  fronl  of  the  liml>  for  ;i  distance  of  six  inches.  The  flexor  muscles 
of  the  forearm  were  stripped  of  their  fascial  covering  over  a  similar  area.  The 
bones  were  uninjured.  The  elbow-joint  was  not  opened.  The  wound  had  been 
received  within  an  hour  from  the  time  the  patient  entered  the  hospital.  ( >n 
the  inner  side  of  the  limli  the  lower  two  indies  of  the  brachial  artery  were 
exposed  in  the  wound,  and  the  vessel  was  separated  for  a  like  distance  from 
ils  attachments.  The  vessel  pulsated  freely,  and  the  pulsations  of  the  radial 
and  ulnar  arteries  at  the  wrist  were  easily  felt.  The  wound  was  cleansed  and 
dressed  carefully  according  to  the  methods  in  vogue  at  that  time  (1886). 
Within  twenty-four  hours  the  pulsation  of  the  radial  and  ulnar  arteries  al 
the  wrist  had  ceased,  and  the  hand  had  become  cold.  Examination  of  the 
wound  showed  that  the  brachial  artery  no  longer  pulsated.  It  had  become 
filled  with  a  thrombus.  Later  the  forearm  became  gangrenous;  a  mixed  Bapre- 
mia  ami  septicemia  occurred.  Amputation  was  done  ;it  the  upper  third  of 
the  arm.     The  patient  did  not  survive. 

Infection  of  Contused  and  Lacerated  Wounds. — Contused  and  lacerated 
wounds,  from  the  nalure  of  their  production  and  from  the  diminished  vitality 
of  the  tissues,  are  not  only  more  apt  to  he  infected  than  other  wounds,  Imt  the 
infection  is  of  a  more  serious  character.  The  pyogenic  cocci  find  a  favorable 
soil  for  their  development,  as  do  also  other  infectious  germs  and  saprophytes. 
The  diagnosis  of  infection  in  such  wounds  is  usually  easy.  They  are  peculiarly 
liable  to  the  spreading  phlegmonous  or  necrotic  infections  caused  by  Strepto- 
coccus pyogenes,  to  cellulitis,  lymphangitis,  to  pocketing  of  pus  f\\\r  to  the 
irregular  shape  of  the  wound  cavities,  and  to  constitutional  infections,  septic 
intoxication,  sapremia,  septicemia,  and  pyemia  (see  diagnosis  of  these  dis- 
eases). The  constitutional  depression  following  immediately  upon  the  receipt 
of  these  injuries  is  often  grave,  irrespective  of  injuries  of  special  organs. 

Diagnosis  of  Contused  and  Lacerated  Wounds  from  a  Medico-legal  Point  of 
View. — In  the  diagnosis  of  contused  and  lacerated  wounds  it  sometimes  hap- 
pens that  from  a  medico-legal  point  of  view  if  is  important  to  know  the 
character  of  the  instrument  which  produced  the  wound.  In  this  connection 
it  is  to  be  remembered  that  stones,  sticks,  clubs,  and  the  like,  when  broughl  into 
violent  contact  with  a  layer  of  soft  parts  covering  hone,  may  produce  a  wound 
which  closely  resembles  in  shape  the  outline  of  the  object  which  caused  the 
wound.  rl  nis  is  especially  noticeable  in  wounds  of  the  scalp,  where  the  soft 
parts  are  cut  between  the  objeel  and  the  surface  of  the  skull  along  the  line 
of  contact.     Under  such  circumstances  the  shape  of  the  wound  may  accurately 

represent    in  size  and  shape  the  end  of  the  -tone,  eluh,  or   the  like,   with   which 

a  blow  was  struck.     Moreover,  such  wounds  may  be  Linear  in  form,  and  may 


8  WOUNDS 

show  very  little  contusion  of  the  wound  edges;   they  may  closely  resemble 
wounds  made  by  a  sharp  instrument. 

INCISED    WOUNDS 

Incised  wounds  are  those  made  by  sharp  or  cutting  instruments:  knives, 
swords,  pieces  of  glass,  etc.  They  are  such  wounds  as  are  made  by  the  surgeon's 
knife.  They  possess  several  characters  which  serve  to  distinguish  them. 
Among  these  are  pain,  a  marked  tendency  to  gape,  and  bleeding. 

The  Pain  of  Incised  Wounds. — It  is  most  acute  at  the  moment  of  their 
infliction.  The  sharper  the  instrument  the  less  the  pain.  The  skin,  the  nerves, 
and  bone  are  the  most  sensitive  structures  when  cut.  Those  regions  of  the 
body  most  plentifully  supplied  with  cutaneous  nerves  hurt  most  when  cut: 
the  face,  the  genitals  and  anal  region,  and  the  fingers  and  toes.  The  pain 
of  an  incised  wound  diminishes  to  a  dull  ache  soon  after  the  infliction  of  the 
injury,  and  soon  disappears  entirely,  unless  irritated,  mechanically  by  motion, 
chemically  by  dressings,  or  by  infection.  The  after  pain  of  even  so  extensive 
a  wound  as  an  amputation  of  an  extremity  is  not  usually  severe,  and  subsides 
entirely  in  twenty -four  hours  or  less,  if  infection  does  not  occur. 

A  very  valuable  diagnostic  sign,  then,  in  the  case  of  incised  wounds  is 
the  presence  or  absence  of  pain  during  the  days  following  their  infliction.  If 
no  spontaneous  pain  exists,  and  no  marked  tenderness  on  pressure,  the  surgeon 
may,  with  certain  exceptions,  feel  assured  that  the  wound  is  not  infected,  is 
doing  well,  and  does  not  need  to  be  inspected  or  disturbed,  except  in  cases 
where  the  patient  is  unconscious,  or  where  strangulation  or  gangrene  of  an 
entire  limb  may  be  present.  This  absence  of  pain  is  one  of  the  most  valuable 
guides  in  the  treatment  of  incised  wounds.  The  pain  of  divided  sensitive 
nerves  is  acute  at  the  moment  of  infliction,  but  subsides  speedily  if  the  nerve 
be  clean-cut  and  completely  divided.  Loss  of  sensibility  will,  of  course,  be 
noted  in  the  area  supplied  by  the  nerve. 

The  Gaping  of  Wounds. — The  gaping  varies  much  in  different  regions  of 
the  body,  also  according  to  the  depth  and  direction  of  the  wound.  In  situations 
where  muscular  layers  are  intimately  adherent  to  the  skin,  incised  wounds 
gape  much  more  when  made  across  the  line  of  the  muscles  than  when  made 
parallel  to  the  direction  of  their  fibers.  Wounds  made  in  the  long  axis  of  a 
limb  gape  less,  as  a  rule,  than  do  wounds  made  transversely  thereto. 

Bleeding. — The  rapidity  of  bleeding  from  a  recently  incised  wound  depends 
upon  the  number  and  size  of  the  blood-vessels  divided.  The  character  of  the 
bleeding  varies  with  the  character  of  the  divided  vessels — whether  arteries  or 
veins.  A  third  variety  of  bleeding  is  sometimes  known  as  parenchymatous 
bleeding.  It  occurs  from  certain  regions,  notably  the  corpora  cavernosa  penis 
and  corpus  spongiosum,  the  mucous  membrane  covering  the  turbinated  bones 
of  the  nose,  and  some  of  the  glandular  organs  of  the  abdomen.  The  blood  is 
a  mixture  of  arterial  and  venous  blood  from  small  but  numerous  vessels  of  both 


PI  \<  TUBED    WOUNDS  9 

kind-.  A  fourth  kind  of  bleeding  occurs  as  an  oozing  from  the  smallest  blood- 
vessels, ilif  capillaries,  and  only  under  exceptional  circumstances  is  il  of  seri- 
ous significance.  Loss  of  blood  is  well  borne  by  strong,  bealthy  adults;  better 
by  women  than  by  men;  badly  borne  by  infants  and  persons  of  advanced 

The  Division  of  Muscles  and  Tendons  in  Incised  Wounds. — Division  is  to  be 
recognized  by  loss  of  function  of  the  injured  muscles  and  ly  seeing  the  cut 
structures  by  direct  inspection  of  the  wound.  During  inspection  of  an  open 
wound  the  cut  surfaces  of  divided  muscles  can  hardly  escape  observation,  but 
divided  tendons  may  escape  the  notice  of  a  careless  surgeon.  This  is  notably 
true  in  wounds  of  the  hand  and  wrist,  where  numerous  tendons  are  present 
The  proximal  portion  of  the  tendon  may  often  1"-  retracted  oul  of  sight  into 
its  sheath,  and  the  distal  portion  may  be  partly  or  entirely  hidden  by  overlying 
parts,  or  on  account  of  the  position  of  the  limb.  It  is  therefore  wise  t. 
the  function  of  all  the  muscles  which  might  be  injured  in  a  wound,  and  to 
make  the  inspection  of  the  wound  in  a  careful  and  systematic  manner. 

The  Division  of  Nerve  Trunks  in  an  Incised  Wound. — This  may  be  recognized 
partly  by  direct  inspection  and  partly  by  loss  of  function,  motor  and  Bensory, 
of  the  affected  nerve.  As  pointed  out  under  the  head  of  Contused  and  Lacer- 
ated Wounds,  the  less  of  motor  function  is  apt  to  be  more  complete  than  is 
the  loss  of  sensibility,  and  is  a  more  dependable  and  positive  sign.  The  motor 
paralysis  in  cases  of  division  of  large  nerve  trunks  is  quite  characteristic.  In 
addition  to  paralysis  of  motion  and  sensation,  the  area  supplied  by  the  divided 
nerve  usually  feels  subjectively  and  objectively  colder  than  normal;  rarely  there 
may  he  a  temporary  increase  of  temperature.  After  the  paralysis  has  existed 
for  some  days,  changes  in  the  nutrition  of  the  skin  may  occur:  the  skin  may 
perspire  abnormally  or  he  abnormally  dry;  the  surface  may  he  unnaturally 
pale,  or  blue  and  cyanotic;  atrophy  and  even  gangrene  of  a  portion  of  an 
extremity  may  occur,  this  being  notably  the  case  in  the  fingers  and  toe-:  chronic 
ulcerations  may  form  in  parts  subjected  to  pressure.  Later  on.  disturbances  in 
the  nutrition  of  the  hones  and  the  joints  are  common,  leading  sometimes  to 
chronic  effusions  into  the  joints,  later  to  ankylosis,  and  the  paralyzed  portion 
of  the  limb  may  undergo  atrophy  of  all  its  structure-. 

PUNCTURED    WOUNDS 

Punctured  wounds  are  of  small  caliber  and  of  relatively  great  depth.  They 
are  produced  by  stabs  with  slender  object-,  such  as  knife  blades,  daggers,  ami 
the  like,  and  by  blows  with,  or  falls  upon,  pointed  sticks,  needles,  and  similar 
bodies.  The  skin  oritice  of  a  punctured  wound  represents  with  fair  accuracy 
the  size  and  shape  of  the  instrument  which  created  the  injury.  Punctured 
wounds  present  a  number  of  interesting  diagnostic  feature-.  Such  wounds 
frequently  penetrate  the  body  cavities:  cranium,  thorax,  abdomen,  anil  the 
large  joints.  The  discussion  of  the  diagnostic  feature-  of  such  penetration 
belongs  properly  under  the  head  of  Regional  Surgery,  and  will  be  there  con- 


10  WOUNDS 

sidered.  A  portion  of  the  instrument  producing  a  punctured  wound  may  be 
broken  off  in  the  tissues,  and  remain  embedded  in  the  depths  of  the  wound. 
For  this  reason  it  is  desirable,  if  possible,  to  inspect  the  instrument  which 
caused  the  wound,  to  see  if  it  is  entire,  and,  by  a  careful  examination  of  the 
part  wounded,  to  exclude  the  presence  of  a  foreign  body. 

Localization  of  Foreign  Bodies  in  Punctured  Wounds. — Slender  foreign  bodies 
like  needles  may  remain  indefinitely,  if  clean,  embedded  in  the  tissues,  and 
may  wander  slowly  or  quite  rapidly  to  near  or  distant  regions ;  muscular  action 
hastens  or  causes  this  result.  When  a  patient  presents  himself  with  the  history 
that  a  needle,  or  the  like,  has  become  embedded  in  the  tissues,  it  is  unwise  to 
assume  that  the  position  of  the  object  has  remained  unchanged  since  its  intro- 
duction. Before  making  an  effort  to  remove  such  an  object  through  an  incision, 
it  should  be  accurately  localized.  Failure  to  do  this  will  often  lead  to  fruitless 
search  in  the  vicinity  of  the  original  wound  for  an  object  already  some  distance 
away.  By  palpation  the  presence  of  such  foreign  bodies  may  sometimes  be 
detected.  Sometimes  pressure  made  upon  a  particular  point  or  in  a  particular 
direction  may  elicit  pain,  and  serve  as  a  guide  to  a  foreign  body.  If  the  body 
be  a  piece  of  metal  or  glass,  it  may  be  detected  by  the  X-rays  by  a  radiograph ; 
less  easily  by  the  use  of  the  fluoroscope  (see  X-rays  in  Surgical  Diagnosis). 
The  danger  of  serious  infection  from  splinters  of  wood,  nails,  etc.,  permitted 
to  remain  in  punctured  wounds,  is  very  great.  Such  bodies  are  commonly 
contaminated  with  pyogenic  germs,  and  sometimes  with  tetanus. 

Punctured  Wounds  of  Arteries. — Aside  from  the  presence  of  foreign  bodies 
in  punctured  wounds  and  the  perforations  of  body  cavities  and  joints,  the  most 
important  complications  of  punctured  wounds,  of  diagnostic  interest,  are  in- 
juries of  blood-vessels  and  of  nerves.  A  punctured  wound  of  a  large  artery 
is  usually  followed  by  a  gush  of  bright  arterial  blood  as  the  Aveapon  or  instru- 
ment is  withdrawn  from  the  wound,  but  such  external  bleeding  soon  ceases,  as 
a  rule,  and  one  of  several  events  may  follow.  If  the  wound  in  the  artery  is 
small,  the  orifice  may  be  temporarily  or  permanently  closed  by  a  clot,  and 
healing  may  take  place  without  further  hemorrhage. 

Tkaumatic  Aneurism — Arterial  Hematoma. — If  the  wound  in  the  wall 
of  the  artery  is  large,  the  blood  will  continue  to  escape,  but  instead  of  finding 
its  way  through  the  narrow  canal  to  the  surface,  it  may  form  a  tumor  of 
greater  or  less  size,  due  to  the  accumulation  of  blood  among  the  deeper  tissues. 
Such  a  tumor  may  be  of  any  size,  depending  largely  upon  the  size  of  the  blood- 
vessel wounded  and  upon  the  character  of  the  surrounding  tissues.  The  tumor 
will  be  tense  and  elastic,  but  will  not  usually  afford  the  sensation  of  pulsation 
such  as  is  found  in  true  aneurism,  until  it  has  reached  a  considerable  size. 
Such  a  tumor  is  known  as  a  traumatic  aneurism  or  arterial  hematoma  or 
primary  aneurismal  hematoma.  In  traumatic  aneurism,  auscultation  with  a 
stethoscope  over  the  tumor  usually  permits  one  to  hear  a  whirring  or  whizzing 
murmur,  synchronous  with  the  systolic  contraction  of  the  heart  or  with  the 
pulse.     This  systolic  murmur  is  caused  by  the  escape  of  the  blood  through  the 


PUNCTURED    WOUNDS  11 

orifice  in  the  vessel  into  the  surrounding  tissues;  ii  ceases  al  once  it  the  main 
arterial  trunk  be  compressed  upon  the  proximal  side  of  the  injury,  [f  the 
wound  in  tli<'  artery  becomes  closed  by  a  thrombus,  the  tumor  will  persist,  but 
ii"  murmur  will  be  heard. 

In  ;i  case  which  came  miller  my  observation,  tin-  deep  femoral  artery  had 
been  accidentally  punctured  by  the  blade  of  a  scissors  in  Scarpa's  triangle. 
The  wound  in  the  skin  was  very  small,  and  did  not  bleed.  Within  twenty-four 
hours  the  upper  portion  <d'  the  thigh  was  greatly  swollen,  and  a  distincl  mur- 
mur could  be  heard  upon  applying  the  stethoscope  to  the  fronl  of  the  limb,  over 
the  course  of  the  vessel  near  the  wound.  Exploration  showed  thai  the  tumor 
consisted  of  a  large  quantity  of  clotted  and  fluid  blood.  The  puncture  in  the 
wall  of  the  artery  was  about  an  eighth  of  an  inch  in  length 

Aneurismal  Varix  and  Varicose  Aneurism. — It*  a  punctured  wound  injures 
a  large  artery  and  a  neighboring  vein  at  the  same  time,  a  communication  (  which 
is  sometimes  permanent)  may  be  established  between  the  artery  and  the  vein 
i  see  Aneurism). 

Punctured  Wounds  of  Veins. — These  alone  usually  give  rise  to  only  moder- 
ate bleeding,  and  such  bleeding  can  generally  be  readily  controlled  by  pressure 
i  3ee  Varicose  Veins).  The  color  of  the  blood,  the  continuous  character  of  the 
blood  stream,  and  the  moderate  force  of  the  same,  usually  suffice  for  a  diagnosis. 

Punctured  Wounds  of  Nerves. — Punctured  wounds  of  nerves  give  rise  to 
symptoms  which  depend  upon  the  number  of  nerve  fibers  divided.  If  the  nerve 
be  completely  divided,  the  symptoms  will  be  the  same  as  is  the  ease  with 
incised  wounds  of  nerves.  It  sometimes  happens,  however,  in  punctured 
wounds  that  only  a  portion  of  the  nerve  trunk  is  cut  or  injured;  under  these 
circumstances  the  paralysis  of  the  nerve  will  not  be  complete.  The  practical 
bearing  of  this  is  that  such  nerves  frequently  heal  completely  with  regeneration 
of  the  injured  fibers  without  artificial  aid.  Occasionally,  however,  such  an 
injury  may  give  rise  to  the  formation  of  a  fibro-neuroma ;  t<>  the  formation 
of  scar  tissne  in  and  about  the  nerve,  accompanied  by  local  pain  and  tender- 
ness, sometimes  of  a  very  severe  character;  and  to  the  occurrence  of  painful 
spasmodic  contractions  of  the  muscles  supplied  by  the  nerve.  Such  tumors 
formed  upon  a  nerve  trunk  may  necessitate  a  dissection  to  free  the  nerve  from 
the  pressure  <»!'  the  scar  tissue,  or  even  resection  of  the  entire  nerve  trunk 
may  be  required  in  certain  instances,  with  subsequent  suture. 

The  Diagnosis  of  Pyogenic  Infections  in  Punctured  Wounds. — The  diagnosis 
i-  to  be  made  from  the  same  signs  which  are  present  in  other  infected  wound-, 
namely,  by  the  presence  of  the  signs  of  inflammation  in  the  vicinity  of  the 
wound,  and  by  constitutional  disturbances,  fever,  etc.  In  some  instances  the 
local  signs  of  inflammation  may  be  less  evident  than  in  open  wounds.  This 
is  not  only  true  of  punctured  wounds  of  joint-  and  body  cavities,  but  also  of 
deep  punctured  wounds  elsewhere.  r|'he  oritice  of  the  wound  may  appear  (dean 
or  even  healed,  although  the  Aery  portion  of  the  wound  may  be  the  -eat  of 
abscess  or  of  spreading  necrotic  inflammation.     The  si^ns  of  pain  and  tender- 


12  WOUNDS 

ness  will,  however,  be  marked,  and  the  constitutional  disturbance  will  often 
be  severe.  Some  of  the  most  dangerous  and  fatal  forms  of  infection  follow 
small  punctured  wounds,  such  as  occur  from  a  needle  puncture  of  a  finger 
during  surgical  operations  and  autopsies  made  upon  those  ill  or  dead  of  acute 
septic  processes  of  various  kinds.  In  these  cases  the  local  reaction  in  the  wound 
may  be  so  slight  as  scarcely  to  be  noticeable,  and  the  sudden  advent  of  grave 
constitutional  symptoms  may  be  the  first  indication  of  trouble  (see  Septic  In- 
toxication, Septicemia,  etc.). 

POISONED    WOUNDS 

We  use  the  term  poisoned  wounds  here  to  indicate  that  some  specific 
poisonous  material  is  introduced  into  the  wound  at  the  time  of  its  infliction 
other  than  bacteria  or  their  toxins,  and  include  under  the  head  of  poisoned 
wounds  snake  bites,  poisoned  arrow  wounds,  and  the  bites  and  stings  of  insects. 

Snake  Bites 

The  diagnosis  of  snake  bites  is  usually  entirely  simple.  The  history  leaves 
the  matter  in  no  doubt.  The  symptoms  of  poisoning  occur,  for  the  most  part, 
very  soon  after  the  injury,  and  are  characteristic.  The  matter  of  treatment 
is  of  far  greater  consequence  than  the  entirely  evident  diagnosis.  The  question 
may,  however,  arise  as  to  whether  the  snake  was  poisonous  or  not,  and  this 
may  sometimes  be  determined  by  a  few  simple  data  given  below.  Inasmuch  as 
the  United  States  has  assumed  control  of  a  number  of  tropical  countries  where 
poisonous  snakes  abound,  the  matter  of  snake  bites  assumes  a  new  interest  for 
American  surgeons.  In  the  Philippine  Islands  the  cobra  and  other  allied 
Indian  species  are  fairly  numerous,  and  on  the  Isthmus  of  Panama  there  are 
many  poisonous  snakes.  The  number  of  poisonous  snakes  in  the  United  States 
itself  is  considerable.  They  are  more  abundant  in  the  southern  and  western 
sections  of  the  country  than  in  the  east  and  north.  Owing,  however,  to  their 
rather  sluggish  habits,  many  of  them,  although  their  venom  is  deadly,  are 
not  so  dangerous  as  in  tropical  countries  where  poisonous  snakes  are  not  only 
numerous,  but  exceedingly  active  and  hostile  to  man. 

That  order  of  the  Reptilia  known  as  snakes,  or  "  Ophidia,"  is  divided  into 
two  suborders :  the  Colubrides,  many  of  them  harmless,  and  the  Vipers,  all 
of  them  poisonous.  The  only  marked  distinction  between  the  poisonous  and 
nonpoisonous  snakes  is  the  presence  in  the  poisonous  varieties  of  poison  glands, 
of  poison  fangs,  and  of  a  muscular  apparatus  for  the  injection  of  the  poison. 
ISTonpoisonous  snakes  have  poison  glands,  but  since  they  do  not  communicate 
directly  with  the  fangs  the  bites  of  such  snakes  are  harmless.  The  poison 
appears  to  be  necessary  to  them  for  purposes  of  digestion.  A  broad  distinction 
may  be  made  between  the  poisonous  and  the  nonpoisonous  snakes,  according 
to  the  arrangement  of  the  teeth.  In  the  nonpoisonous  snakes  there  are  two 
complete  rows  of  teeth — maxillary  and  palatine — arranged  in  two  nearly  paral- 


POISONED    WOUNDS  13 

lei  rows.  The  palatine  teeth  number  from  thirty  five  to  forty.  The  teeth  are 
nil  -mall  as  compared  with  the  Bize  of  the  poison  fangs  of  the  venomous  snakes. 
The  only  poisonous  snakes  having  m  similar  arrangemenl  are  the  poisonous 
sea  anakes  i  Eydrophida).  The  poisonous  snakes  have  fewer  palatine  teeth, 
the  Colubrides  have  about  twenty-five,  and  the  Vipers  from  eight  to  ten.  In 
the  Vipers,  the  maxillary  teeth  consist  of  two  mature,  I- -mr.  sharp,  recurved, 
hollow  poison  fangs  rigidly  articulated  to  the  movable  maxilla.  The  dud  of 
the  poison  gland  empties  into  the  base  of  the  hollow  fang.  When  at  rest,  the 
fanes  lie  embedded  in  the  folds  of  the  lining  membrane  of  the  month.  When 
the  snake  opens  its  month  to  strike,  the  movable  maxilla  is  rotated  BO  thai  the 
fang  is  erected  and  projects  forward. 

In  some  of  the  viperine  snakes  a  series  of  undeveloped  poison  fangs,  two 
or  more  in  number,  lie  behind  the  mature  fangs,  and  take  their  place  it  the 
latter  are  shed  or  injured.  The  fangs  of  the  Viper-,  together  with  the  poison 
glands,  form  a  mechanical  arrangement  closely  resembling  in  its  action  that 
of  a  hypodermic  Byringe.  At  the  moment  of  striking,  the  fangs  are  erected 
and  the  contents  of  the  poison  glands  are  ejected  by  a  rather  powerful  muscular 
apparatus,  chiefly  by  the  contraction  of  the  temporal  muscles.  As  the  fangs 
reach  their  mark  the  lower  jaw  is  raised,  thus  pressing  the  upper  jaw  against 
the  pari  struck  and  insuring  penetration,  at  the  same  time  forming  a  point 
d'appui  for  the  contraction  of  the  temporal  muscles,  which  not  only  compress 
the  poison  glands  and  eject  the  poison,  but  also  render  the  penetration  of  the 

fangS    deeper. 

In  some  species  the  poison  may  be  expelled  to  a  distance  of  several  feet. 

Colubrine  Snakes. — The  Colubrine  snakes  have  two,  sometimes  three,  max- 
illary fangs  on  either  side.  The  anterior  fang-  is  grooved  for  the  conduction 
of  the  poison.  The  fangs  are  shorter  than  those  of  the  Vipers,  and  are  im- 
movable. In  only  one  group  of  poisonous  snakes  among  the  Colubrines 
is   this   arrangement   of  the 

teeth  departed  from.  Among      em,  •<••.• 

these  there  are  several  long,  .'      /  •  .•'        :•  /  •      \  \ 

grooved  poison  fangs  in  the       a    \      •  \        :  •    '.       •'    \ 

hack  of  the  month,  while  in  :     •  \      •  c   \     \     i     j 

front  there  are  two  smooth,  j     •  :      •  •     • 

nongrooved  teeth.    Owing  to 
the   position   of   the   poison 

x  ,1  i  -j       Fig.  1. — Diagram  to  Illustrate  the  General  Arrange] 

iangs    iliese    snakes    are    set-  of  the  Teeth  in  Poisonous  un>  Non-Poisonous  Snakes. 

.lom  dangerous  to  man.     It         £n^f£^    *  Cobra"     ('-  NonPoisonoua  Snak"-     f>  1Vi" 

Will    thus    he   seen,    -peaking 

broadly,  that  when  an  individual  is  bitten  by  a  snake  the  tooth  marks  may 
furnish  fairly  positive  proof  as  t«>  whether  or  not  the  bite  is  dangerous, 
(See  Fig.  1,  showing  the  mosl  frequenl  arrangements  of  the  teeth  in  the 
poisonous  and  nonpoisonous  snakes,  respectively.)  Where  only  two  good-sized 
punctures,  side  by  side,  are  produced,  it  is  certain  that  the  bite  is  poisonous. 


14  WOUNDS 

The  characters  of  the  more  important  poisonous  snakes  are  as  follows: 
Among  the  Colubrides,  the  Proteroglyphia  (having  grooved  teeth)  are  the 
most  important.  They  have  well-developed  fangs,  grooved  along  the  entire 
anterior  surface,  situated  near  the  front  of  the  upper  jaw.  These  teeth  are 
connected  with  the  excretory  ducts  of  the  poison  glands;  the  latter  are  highly 
developed.  Of  these  snakes  there  are  five  families.  The  two  most  impor- 
tant are  the  Hydrophidae,  or  sea  snakes,  all  poisonous,  and  the  Elapidse,  or 
land  snakes. 

Hydeophidj;. — In  the  Hydrophida?  the  head  is  narrow,  the  back  elevated 
into  a  ridge,  and  the  tail  compressed  laterally  to  aid  in  swimming.  The  eyes 
are  small  and  the  pupils  round.  These  snakes  swim  very  rapidly,  although 
slow  and  clumsy  upon  the  land.  They  live  in  large  colonies,  swim  far  out 
to  sea,  and  are  exceedingly  bold  and  vicious.  They  inhabit  the  tropical  sea- 
coasts  of  Asia  and  the  tropical  islands  of  the  Pacific. 

Elapid^e,  or  Land  Snakes. — These  furnish  the  most  dangerous  snakes  in 
the  world,  including  the  cobra — JSTaja  tripudians,  Cobra  de  capello,  Hooded 
Cobra.  They  have  a  slender,  cylindrical  tail,  smooth  or  wedge-shaped  scales ; 
some  of  them,  when  excited,  spread  the  neck  laterally  until  it  is  wider  than 
the  head.  The  expansion  is  produced  by  a  movement  of  the  elongated  first 
few  pairs  of  ribs ;  these  are  brought  forward  at  right  angles  to  the  spine,  thus 
forming  the  so-called  hood.  These  snakes  are  found  in  Asia,  Africa,  jSTorth 
and  South  America,  and  Australia.  In  America  many  of  them  are  known  by 
the  name  of  coral  snakes.  The  true  coral  snakes,  however,  are  found  only  in 
the  forests  of  tropical  South  America  and  in  the  State  of  Florida. 

The  American  members  of  the  genus  Elaps  are  small  snakes,  not  exceeding 
three  feet  in  length ;  they  live  in  the  woods ;  their  poison  is  very  powerful,  but, 
owing  to  the  position  of  the  fangs  far  back  in  the  mouth,  they  are  not  very 
apt  to  produce  a  fatal  bite.  Two  species  are  common  in  the  Southern  and 
Western  States.  The  best  known  is  the  Harlequin  Snake ;  it  is  abundant  in 
Arizona ;  its  bite  is  sometimes  fatal  to  man.  Most  of  the  dangerous  snakes  of 
India  are  Elapinae.  Among  the  genera  are  Bungarus,  Naja,  and  Callophis. 
Bungarus  and  Callophis  are  far  less  dangerous  to  man  than  Naja. 

Bungarus  cozruleus  (Krait). — This  variety  of  snakes  is,  however,  respon- 
sible for  many  deaths.  It  is  a  small  snake,  of  dull  coloration.  The  fangs  are 
smaller  than  in  the  cobra,  and  do  not  penetrate  so  deeply ;  but,  according  to 
Fayrer,  it  is,  next  to  the  cobra,  the  most  dangerous  snake  to  human  life  in 
India. 

Na.ta  tripudians. — This  best  known  and  most  dreaded  of  all  reptiles  is 
abundant  in  India,  Burmah,  and  the  Malayan  archipelago.  They  have  a 
pattern  on  the  back  of  the  neck  resembling  a  pair  of  spectacles.  They  are 
also  found  throughout  every  part  of  tropical  Asia.  They  lay  about  twenty 
soft  eggs  the  size  of  a  pigeon's  egg.  The  cobra  is  not  afraid  of  man,  and  will 
enter  houses  at  night  in  search  of  rats,  mice,  or  other  food.  If  not  molested, 
they  are  said  to  live  at  peace  with  the  human  inhabitants. 


POISONED    WOUNDS  15 

A  closely  allied  Bpecies,  much  larger  in  size  though  by  no  means  as  numer- 
ous, ie  [Iamadryas  ophiophagiis  elaps-  snake  eater.  'I  bis  snake  grows  to  a 
length  of  fourteen  feet;  it  much  resembles  the  cobra  in  range  and  habits,  but 
owing  to  its  size  is  more  dangerous.  It-  favorite  food  is  other  Bnakes.  It  i- 
valued  by  snake  charmers  on  accounl  of  its  docility  in  captivity.  They  are 
careful  to  extrad  the  fangs. 

In  Africa  there  are  a  number  of  species  closely  allied  to  the  Indian  cobra; 
among  the  besl  known  is  the  Egyptian  cobra,  or  asp — NTaja  Ilaje.  The  snake 
grows  to  a  length  of  six  feet  Other  species  of  Naja  an-  abundant  throughout 
equatorial  Africa. 

All  the  poisonous  snakes  of  Australia  are  Colubride  snakes.  The  most 
common  are  the  I  Hack  Snake.  Tiger  Snake,  and  Death  Adder  |  Pseudechis  por- 
phyriacus,  Eloplocephalus  curtus,  and  Acanthophis  cerastinus). 

Viperidae. — All  the  viperine  snake-  are  poisonous.  They  comprise  the 
Viperida?  and  Crotalidae.  They  are  distinguished  by  a  short  triangular  head 
and  a  stout  body  with  a  short  tail.  The  poison  fangs  are  long  ami  well  devel- 
oped; they  are  hollow,  not  grooved.  The  bones  of  the  upper  jaw  are  movable, 
and  the  fangs  are  erected  by  muscular  action.  These  snakes  abound  in  Europe, 
Asia,  Africa,  and  America,  hut  are  not  found  in  Australia.  This  group  eon- 
tains  nearly  all  the  important  poisonous  snakes  of  America. 

Tn  America  there  are  no  true  vipers,  but  the  Pit  vipers  are  very  common. 
They  have  a  very  broad  head,  imperfectly  covered  by  scales,  and  are  character- 
ized hv  the  presence  of  a  deep  pit  on  either  side,  hehind  the  nostril  and  in 
front  of  the  eye.  Some  of  them  have  a  series  of  horny,  loosely  jointed  rings 
fche  end  of  the  tail.  When  the  snake  is  startled  or  excited  it  vibrates  the  rail 
rapidly,  and  the  peculiar  sound  thus  produced  gives  origin  to  the  name  rattle- 
snake.    There  are  three  genera:  Crotalus,  Lachcsis,  and  Ancistrodon. 

Ceotalus. — This  snake  is  found  only  in  America,  throughout  the  United 
States  as  far  north  as  Xew  York,  and  in  South  America  as  far  south  as  Brazil. 
There  are  in  the  United  States  some  fourteen  or  more  varieties  of  rattlesnakes. 
They  are  easily  recognized  hv  the  presence  of  a  jointed,  horny  rattle  at  the 
end  of  the  tail,  u<a]  hv  the  snake  to  make  known  it-  presence  and  to  warn 
intruders,  ami  by  the  broad  head,  and  the  dee])  pit  in  front  of  the  eye.  The 
rattlesnake  strikes  from  a  coil  by  rapidly  straightening  the  body  in  the  direc- 
tion of  the  thing  to  he  bitten.  They  are  unable  to  throw  the  entire  body 
from  the  ground,  and  can  only  strike  an  object  distant  two  thirds  of  their 
own  length.  The  best  known  variety  as  well  as  the  largest  is  Crotalus  ada- 
manteus,  the  Diamond-hack  Rattler.  This  snake  may  attain  a  length  of  about 
eight  feet,  this  being,  however,  an  unusual  size.  The  fangs  of  such  a  snake 
may  he  a  full  inch  in  length.  Tt  is  most  abundant  in  the  Southern  States. 
The  northern  species — the  handed  rattlesnake.  Crotalus  horridus- — is  from  three 
to  four  feet  in  length.  Tt  is  very  common  in  the  Rocky  Mountains,  and  in 
the  desert  regions  to  the  west  and  south.  Other  varieties  of  the  Pit  Viper, 
less  dangerous   than   the  rattlesnake,   are  the   Copperhead    (Ancistrodon   con- 


16  WOUNDS 

tortrix),  of  a  banded  copper  color,  seldom  longer  than  three  feet,  known  also 
as  the  Pilot  Snake,  Upland  Moccasin,  and  Deaf  Adder,  habitat  the  United 
States,  east  of  the  Rocky  Mountains;  the  Water  Moccasin  (Ancistrodon  pis- 
civorus),  habitat  bayous  and  swamps  in  the  Southern  States,  an  ugly  snake 
of  a  dirty  brown  or  mud  color,  extreme  length  five  feet,  diameter  three  inches ; 
it  is  also  called  Cotton-mouth,  from  the  white  color  of  the  interior  of  its 
mouth. 

A  closely  allied  species  is  Lachesis  (the  Per  de  lance,  or  Lance-headed 
Snake),  a  native  of  the  West  India  Islands,  extreme  length,  six  feet;  the  head 
is  wide,  the  fangs  long,  color  brown,  with  black  markings.  In  the  Island  of 
Martinique  the  snake  has  caused  a  considerable  annual  death  rate  among  per- 
sons working  on  the  sugar  plantations. 

One  of  the  largest  and  most  deadly  of  the  Pit  Vipers  is  the  Lachesis  Muta 
(or  Lachesis  rhombeata),  sometimes  called  Surucucu,  or  Buschmeister  (Bush 
Master).  This  snake  inhabits  the  elevated  woodlands  in  many  of  the  tropical 
and  subtropical  countries  of  South  America,  Brazil,  the  Gluianas,  and  neigh- 
boring States.  It  lives  upon  the  ground,  and  is  not  a  tree  climber.  It  is  said 
to  grow  to  a  length  of  eight  feet  or  more,  with  a  girth  equal  to  that  of  a  man's 
leg.  The  general  form  and  habits  of  the  animal  are  similar  to  those  of  the 
rattlesnake.  It  is  a  handsome  snake.  .  The  back  is  colored  a  bright  reddish 
yellow,  with  a  longitudinal  row  of  large  rhombic,  dark,  blackish-brown  spots, 
each  with  two  small  bright  spots  within  its  area.  The  end  of  the  tail  is  armed 
with  horny  scales  ending  in  a  spine.  The  belly  is  bright  yellow,  or  pearly. 
The  snake  is  said  to  be  very  aggressive,  sometimes  lying  quietly  coiled  until 
the  near  approach  of  an  intruder,  and  striking  like  a  flash  when  he  comes 
within  range,  or  in  other  instances  advancing  rapidly  along  the  ground  to 
attack  man  or  lower  animals.  Unlike  the  rattler,  there  is  no  warning  sound 
given  by  this  snake.  The  symptoms  come  on  soon  after  the  bites ;  hemorrhages 
from  mucous  membranes,  rigidity  and  loss  of  voluntary  control  of  the  muscles, 
are  said  to  be  marked  symptoms.  Death  may  occur  in  from  six  to  twelve 
hours. 

The  true  vipers  are  not  found  in  America.  They  are,  however,  the  only 
poisonous  snakes  of  the  Continent  of  Europe,  and  are  represented  by  several 
species.  The  commonest  is  Vipera  Berus.  None  of  them  are  large  snakes ; 
they  are  seldom  longer  than  two  feet.  They  are  found  spread  over  the  entire 
Continent,  notably  in  mountainous  regions.  Various  members  of  the  viper 
family  are  found  in  Africa:  the  Horned  Viper  (V.  cerastes)  in  the  northern 
part;  farther  south,  the  Puff  Adder  (Bitis  arietans).  This  snake  attains  a 
length  of  five  feet.  In  striking  it  is  said  to  throw  its  entire  body  off  the 
ground,  so  that  it  might  even  wound  a  man  on  horseback.  Its  venom  is  used 
by  the  Hottentots  to  poison  their  arrow  tips. 

In  India  and  Burmah  there  are  found  large  vipers,  Echidna  Elegans,  a 
richly  colored  snake,  growing  to  a  large  size.  Other  and  dangerous  vipers  are 
found  in  Japan  and  in  Tibet. 


POISONED    WOUNDS  17 

Snake  Venom. — Snake  venom  is  ;i  clear,  watery  <>r  viscid  fluid,  of  a  pale 
yellow  or  amber  color,  of  a  specific  gravity  of  from  L.030  to  L.070.  Ii  is 
higher  in  Crotalidae  than  is  Colubridse,  faintly  acid  in  reaction.  In  the  dried 
state  the  poisonous  properties  are  preserved  indefinitely.  The  dried  venom 
breaks  up  into  numerous  minute  flakes  resembling  dried  egg  albumin.  Weir 
Mitchell  preserved  Crotalus  venom  for  twenty-three  years  without  perceptible 
loss  of  activity.  Venom  is  qoI  destroyed  by  light  nor  by  freezing.  It  ie 
destroyed  by  a  temperature  of  !<><>  < '.  after  a  Bhorl  time.  Snake  venom 
the  ordinary  proteid  reactions.  The  amounl  of  venom  excreted  al  a  single  bite 
varies  with  the  size  of  the  snake,  and  with  the  time  which  has  elapsed  since 
the  previous  bite.  Snakes  in  captivity  sometimes  deteriorate  in  health,  and 
often  refuse  food.  The  quantity  of  the  venom,  and  its  toxicity,  is  thereby 
diminished.  It  is  probable  thai  more  venom  is  furnished  when  the  snake  bitea 
than  when  the  poison  glands  are  squeezed  with  the  fingers  and  the  venom 
thus  obtained.  The  amounl  "I  venom  yielded  by  squeezing  the  gland  has  been 
determined  experimentally  in  a  number  of  important  snakes.  The  weight  in 
the  following  figures  is  estimated  in  the  dried  state:  Cobra,  X.  tripudians, 
0.254  (Cunningham),  from  a  bite  0.373  i  Lamb);  Lachesis,  Fer  de  lance,  0.127 
(Calmette)  ;  ('retains  adamenteus,  0.309  0.179   (Flexner  and   Noguchi). 

The  Chemistry  <>k  Snake  Venom. — The  chemistry  of  snake  venom  is 
hut  little  understood.  The  general  result  of  the  several  investigations  which 
have  been  made  is  that  venom  contains  two  actively  poisonous  ingredients. 
They  have  been  named  Venom  Peptone  and  Venom  Globulin.  The  action  of 
each  of  these  is  different ;  venom  peptone  causes  edema,  putrefaction,  and 
necrosis  of  the  tissues;  venom  globulin,  on  the  other  hand,  acts  through  the 
nerves  upon  the  muscles  of  respiration  and  the  circulatory  apparatus.  It 
destroys  the  coagulability  of  the  blood,  causes  ecchymosis,  lowers  the  blood- 
pressure,  and  paralyzes  respiration.  While  all  snake  venoms  contain  the  same 
poisonous  ingredients  and  have  the  same  action  upon  the  animal  organism, 
vet  it  has  been  found  that  the  venom  of  different  kinds  of  snakes  contain  the 
poisonous  principles  in  varying  proportions,  so  that  the  symptoms  produced 
will  vary  quite  markedly  after  the  bites  of  serpents  of  different  kinds.  The 
following  details  are  largely  adapted  from  the  work  of  Flexner  and  Noguchi. 
The  poisonous  principles  may,  according  to  their  action,  be  classified  as 
follows : 

1.  A   principle  which  produces   instantaneous  coagulation  of  the  hi 1   in 

the  vessels. 

2.  A  principle  which  acts  upon  the  nervous  system. 

.'!.  A  principle  which  causes  rupture  of  the  walls  of  the  capillary  vessels 
and  extensive  hemorrhage. 

I.    A  principle  which  causes  solution  id"  the  blood-corpuscles. 
5.   A  number  of  principles  destructive  t<>  tissue  cells. 
ii.   A  principle  which  causes  hardening  of  the  red  blood-corpuscles, 
7.    Loss  of  the  bactericidal  property  of  the  blood. 


18  WOUNDS 

1.  The  Blood-clotting  Principle. — The  venom  of  certain  snakes  has  a 
marked  influence  on  the  coagulation  of  the  blood.  In  large  quantities  it 
causes  instant  coagulation  of  the  blood  within  the  vessels.  In  smaller  quan- 
tities it  destroys  the  power  of  the  blood  to  coagulate  for  a  long  time.  Venoms 
of  this  class  are  capable,  under  certain  circumstances,  of  causing  instant  death 
by  widespread  coagulation  of  the  blood.  The  symptoms  produced  are  giddi- 
ness, loss  of  consciousness,  general  convulsions,  and  death  in  a  few  minutes. 
Death  has  been  known  to  occur  in  half  a  minute.  The  blood  is  found  coagu- 
lated in  the  vessels,  more  especially  in  the  pulmonary  arteries  and  the  right 
side  of  the  heart.  The  snakes  capable  of  this  form  of  poisoning  are :  Crotalus 
adamanteus,  Daboia  russellii,  Bungarus  fasciatus,  Hoplocephalus  curtus  (an 
Australian  snake),  Tiger  snake,  Echis  carinata  (an  Egyptian  viper),  Pseu- 
dechis  porphyriacus,  Black  snake  (Australia),  Trimeresurus  riukiuanus  (a 
Japanese  viper). 

2.  The  Neurotoxin  of  Venom. — The  venoms  containing  the  largest  pro- 
portion of  this  ingredient  are  those  of  cobra  and  Bungarus  (Krait),  though 
they  are  found  in  larger  amount  in  all  of  the  Elapidae  and  Hydrophidae  than 
in  the  Viperina?.  These  venoms  may  produce  death  in  a  few  minutes.  The 
smallest  lethal  dose  of  cobra  venom  causes  death  in  two  or  three  days.  The 
local  symptoms  caused  by  neurotoxic  venoms  are  trifling:  slight  edema,  some- 
times ecchymosis.  The  nervous  symptoms  are  marked.  They  come  on  almost 
at  once,  and  are  stupor,  muscular  weakness  followed  by  paralysis,  twitching 
of  the  muscles,  dyspnea,  cessation  of  breathing,  and  death.  A  large  dose  of 
cobra  or  of  Bungarus  venom  produces  identical  symptoms.  A  small  dose  of 
Bungarus  venom  causes  a  chronic  form  of  poisoning.  There  may  be  no  marked 
symptoms  for  several  days,  when  muscular  weakness,  profound  mental  and 
physical  depression,  loss  of  appetite,  and  emaciation  appear,  and  are  pro- 
gressive until  death.     The  exitus  may  be  delayed  for  a  fortnight. 

3.  The  Principles  Causing  Hemorrhage. — The  poison  of  vipers  and  rattle- 
snakes is  rich  in  this  principle,  and  the  most  striking  symptoms  of  rattlesnake 
bite  are  the  profuse  and  continuous  bleeding  from  the  wound,  and  the  rapidly 
progressive  swelling  and  ecchymosis  of  the  part  bitten.  The  extent  of  the 
tissues  thus  affected  varies  according  to  the  amount  of  the  poison,  but  it  may 
continue  to  advance  for  several  days,  involving  the  entire  limb,  or  even  the 
entire  side  of  the  body.  The  walls  of  the  capillary  vessels  are  extensively 
ruptured,  and  examination  of  the  tissues  shows  that  blood  is  extravasated  into 
all  the  soft  tissues  of  the  limb.  One  of  the  worst  features  of  rattlesnake  bite 
is  the  extensive  sloughing  of  the  tissues  thus  affected,  leading  to  loss  of  the 
limb  or  to  deformity  from  extensive  scarring,  and  consequent  impairment  of 
the  muscular  action.  The  principle  producing  edema  is  believed  to  be  different 
from  that  producing  hemorrhage. 

Symptoms  of  Rattlesnake  Bites. — The  symptoms  of  rattlesnake  bite  may 
properly  be  described  here.  They  are :  immediate  severe  pain  in  the  wound ; 
wound  continues  to  bleed ;  rapid  swelling  and  ecchymotic  discoloration  of  limb ; 


POISONED    WOUNDS  19 

later,  bloodv  exudation   into  mi as  membrane  of  nose,  month,  conjunctiva, 

and  hemoglobinuria;  in  fifteen  minutes  or  more,  prostration,  nausea,  vomiting; 
rapid  tall  of  blood-pressure;  respiration  at  firsl  rapid,  later  bIow  and  sterto- 
rous;  muscles,  sometimes  convulsive  twitchings,  followed  by  paralysis.  Death 
may  occur  in  twelve  hours.  Recovery  from  the  general  symptoms  of  intoxi- 
cation occurs  suddenly.  If  the  patienl  survives  the  immediate  effects,  suppura- 
tion, often  extensive,  sometimes  gangrenous,  occur-  near  the  bite.  Death  may 
occur  from  septicemia.  In  cases  where  the  venom  is  injected  directly  int..  a 
laree  vein    rapid  general  thrombosis  may  cause  almosl   instant  death. 

4.  Thfi  Principles- Causing  Solution  and  Agglutination  of  the  Blood  Cells. 
— The  destruction  of  the  blood  cells  is  shown  clinically  by  hemoglobinuria. 
Experimentally,  this  has  been  proven  by  bleeding  a  poisoned  animal  and  allow- 
ing the  blood  to  settle,  when  the  serum  is  found  to  be  blood-stained.  The 
agglutinating  property  of  the  rattlesnake  venom  was  demonstrated  by  Weir 
Mitchell  in  rabbits. 

5.  Principles  Causing  the  Solution  of  Tissue  CeZZs.— Flexner  and  Nogucbi 
found  in  venom  solvent  agents  which  destroyed  the  cells  of  the  liver,  the  kidney, 
testis,  spermatozoa,  and  ova.  but  that  these  agents  required  certain  comple- 
mentary bodies  to  perform  their  solvent  action.  These  bodies  exist  in  the 
body  fluids  or  in  the  cell  body. 

6.  The  Protective  or  Hardening  Property  upon  the  Red  Blood  Cells. — It 
has  been  demonstrated  by  numerous  observers  that  when  snake  venom  is  added 
to  blood,  if  the  venom  is  present  in  large  amount  it  appears  to  harden  the 

red  1»1 1  cells  by  forming,  according  to  Noguchi,  an  insoluble  compound  or 

precipitate  which  prevents  the  escape  of  the  hemoglobin  from  the  cells. 

7.  Loss  of  the  Bactericidal  Property  of  the  Btood. — Following  snake  bites, 
it  has  often  been  observed  that,  though  the  victim  recovers  from  the  immediate 
effects  of  the  poison,  he  may  die  from  a  secondary  pyogenic  infection,  and 
that  under  such  circumstances  there  is  little  or  no  power  on  the  part  of  the 
tissues  for  resisting  the  invasion  of  pyogenic  and  other  bacteria. 

The  Symptoms  of  Cobra  Poisoning1. — The  wounds  made  by  the  fangs  are 
insignificant  punctures.  Burning  pain  and  edema  of  the  surrounding  tissues 
follow.  Constitutional  symptoms  may  appear  in  from  a  few  minutes  to  an 
hour.  They  are  vertigo,  weakness  of  the  extremities,  followed  by  complete 
paraplegia.  There  may  be  convulsive  movements  or  general  convulsions. 
There  i-  plods,  paralysis  of  the  muscles  of  the  jaw  and  throat,  inability  to 
speak  or  swallow.  The  pupils  continue  to  react  to  light.  Consciousness  is 
preserved.  The  pulse  is  rapid,  but  is  of  fair  force  until  just  before  death. 
There  is  finally  paralysis  of  all  the  muscles.  The  respiratory  functions  are 
rapidly  destroyed:  breathing  i-  at  first  rapid,  becomes  slower,  labored,  and 
more  and  more  superficial  until  it  ceases.  The  heart  may  beat  for  some  min- 
utes after  breathing  stops.  The  length  of  time  after  the  bite  before  death 
occurs  varies  a  good  deal,  according  to  the  amount  of  venom  injected.  In 
most  of  the  fatal  cases  death  occurs  in  from  two  to  twelve  hour-  after  the  bite. 


20  WOUNDS 

About  one  fifth  of  the  cases  die  in  less  than  two  hours,  and  one  fifth  after 
twenty-four  hours.  Recovery,  when  it  takes  place,  is  rapid,  and  is  not  followed 
by  the  inflammatory  local  symptoms  usual  after  rattlesnake  bite. 

Mortality. — It  is  believed  that  seven  eighths  of  the  cases  of  rattlesnake 
bites  recover  (Weir  Mitchell).  Other  estimates  are  from  fifteen  to  twenty-five 
per  cent  mortality.  Cobra  bites  are  fatal  in  from  twenty-five  to  forty-five  per 
cent  of  the  cases  (Calmette).  Bites  about  the  face  are  very  dangerous,  as  are 
bites  upon  the  toes  and  fingers,  since  the  wounds  here  are  often  deeper,  the 
size  of  the  fingers  being  more  favorable  for  deep  penetration.  The  minimum 
fatal  dose  of  cobra  venom  for  a  man  is  variously  estimated  at  from  0.01  gm. 
(Calmette)  to  0.0175  gm.  (Lamb). 

Treatment  of  Snake  Poisoning. — A  word  in  regard  to  the  treatment  of  snake 
bites.  If  the  bite  is  upon  a  limb,  instant  tight,  elastic  ligation  of  the  limb  above 
the  bite  should  be  practiced,  or  several  ligatures  may  be  applied,  one  above  the 
other.  If  the  bite  is  upon  a  finger,  the  snake  a  deadly  and  active  one,  and 
the  wounds  deep,  probably  immediate  amputation  of  the  finger  or  toe,  as  the 
case  may  be,  would  be  the  simplest  and  safest  measure.  It  is  dangerous  to 
leave  a  tight  ligature  on  a  limb  for  more  than  half  an  hour.  At  the  end  of 
that  time  it  should  be  loosened  for  a  few  moments  and  reapplied.  If  prac- 
ticable, excision  of  the  wound  is  a  safe  and  proper  measure.  Cupping,  or 
sucking  with  the  mouth,  is  useful  if  done  at  once.  The  mouth  should  be 
rinsed  with  water  or  some  antiseptic  solution  (potassium  permanganate,  1—100). 
The  wound  may  be  destroyed  with  a  hot  iron  or  a  hot  coal.  Certain  chemicals 
have  been  much  used  by  subcutaneous  injection  into  and  about  the  wounded 
tissues.  They  do  no  good  if  injected  at  a  distance.  The  advantage  of  their 
use  is  that  they  may  destroy  the  venom  without  seriously  injuring  the  tissues. 
They  should  be  used  liberally,  and  at  the  earliest  possible  moment.  Among 
those  which  have  been  found  useful  are  potassium  permanganate,  1-100 ; 
chloride  of  calcium  or  hypochlorite  of  calcium,  1-60 ;  chloride  of  gold, 
1-1,000;  chromic  acid,  1-100.  If  the  wounded .  tissues  are  excised,  potas- 
sium permanganate  crystals  may  be  rubbed  into  the  raw  surface. 

General  Treatment. — Stimulants  of  all  kinds  may  be  administered.  Al- 
cohol in  full  but  not  excessive  doses,'  stopping  short  of  profound  intoxication ; 
tea  and  coffee  in  large  doses ;  strychnin  as  the  result  of  experiment  upon  ani- 
mals has  not  been  found  useful.  It  is  nevertheless  recommended  in  full  doses 
by  numerous  observers.  If  respiration  fails,  artificial  respiration  should  be 
used,  and  kept  up  as  long  as  the  heart  continues  to  beat. 

Specific  Treatment. — The  exact  value  of  Calmette's  antivenene  injec- 
tion for  snake  bite  has  not  been  definitely  determined.  It  is  contended  by 
him  that,  although  prepared  by  him  as  an  antidote  to  cobra  poisoning,  it  saves 
life  after  bites  from  this  and  also  after  bites  from  viperine  snakes.  It  is, 
however,  alleged  by  others  that  Calmette's  antivenene  is  not  sufficiently  power- 
ful in  doses  of  20  c.c.  to  save  life  after  a  human  being  has  been  bitten  by  a 
cobra.     The  average  dose  of  poison  injected  at  one  bite  is  many  times  stronger 


POISONED    WOUNDS  21 

than  ili«'  usual  dose  of  antivenene  can  neutralize,  and,  moreover,  thai  although 
Calmette's  serum  contains  Bmall  quantities  of  bodies  capable  of  immunizing 
the  TOnoms  of  other  serpents,  the  quantities  are  too  small  to  render  the  .-«-ru m 
valuable  as  an  antidote  againsl  any  poison  other  than  thai  of  cobra  venom. 
The  truth,  however,  remains  that  the  results  of  Calmette  and  others  in  the 
use  of  antivenene   have   been   encouraging,   and    whenever  antivenene  can    be 

obtained  it  should  be  used  in  every  case  of  snake  bite.     Antiven is  serum 

i-  prepared  in  hermetically  sealed  tubes,  containing  1<»  <•.<•.  In  this  state  it 
will  keep  two  years,  bu1  is  said  to  deteriorate  in  hot  climates.  In  the  dried 
state  it  will  keep  indefinitely,  and  may  !><•  dissolved  in  sterile  water  for  in- 
jection. Antivenene  is  much  more  efficacious  when  injected  into  a  vein  than 
when  introduced  subcutaneously.  It  should  he  u-i-<\  at  once  after  the  bite;  the 
longer  the  delay  the  larger  the  quantity  of  antivenene  necessary  to  neutralize 
the  venom.  Antivenene  should  of  course  not  he  w-n\  to  the  exclusion  "I  other 
acti\e  treatment,  us  already  described. 

Poisoned  Arrow  Wounds 

The  poisons  used  by  savage  tribes  on  the  points  of  their  arrows  and  9pears 

are  of  many  kinds,  ami  produce  very  varied  symptoms.  In  some  cases  there 
i>  hut  a  single  active  ingredient  and  a  single  definite  group  of  symptoms.  In 
others  several  poisonous  ingredients  are  present,  and  the  resulting  symptoms 
are  of  a  mixed  character.  In  an  Encyclopedia  of  Surgery  (  Kocher  and  Que- 
rain,  Leipzig,  1903,  vol.  ii,  p.  300)  there  is  a  short  arti.de  on  the  subjeel  by 
Th.  Ilusemann.  The  following  is  based  largely  on  the  facts  therein  contained. 
Tn  general  it  is  to  he  borne  in  mind  that,  although  the  wounds  produced  by 
poisoned  arrows  are  often  of  a  trifling  character,  being  in  many  instances 
mere  punctures,  the  alkaloid al  poisons  introduced  into  the  wound  are  so  power- 
ful, and  so  readily  taken  up  by  the  circulation,  that  instant  treatment  offers 
the  only  prospect  of  saving  life.  If  symptoms  of  poisoning  are  waited  for, 
it  is  then,  in  most  cases,  too  late.  Immediate,  firm  ligature  of  the  limb  above 
the  wound,  removal  of  the  arrow,  free  incision,  irrigation  of  the  cavity  with 
water  and  mechanical  cleansing  may  save  life.  In  one  of  Stanley'-  Congo 
expeditions,  a  number  of  his  people  Avert1  wounded  by  poisoned  arrows;  all 
died,  soon  after  receiving  the  wound,  with  tetanic  spasms  hut  one;  his  wound 
was  sucked  by  a  comrade,  and  his  life  thus  saved.  It  is  to  be  remembered 
that  these  poisons,  being  alkaloidal,  are  absorbed  readily  through  the  mucous 
membranes  of  the  month,  ami  that  the  mouth  should  he  immediately  cleansed 
after  such  suction  is  practiced.  The  arrow  poisons  of  different  parts  of  the 
world  are  many.  According  to  the  effects  produced,  they  may  he  divided  into 
seven  groups.  The  preparations  vary  much  in  strength  in  different  specimens. 
T.  Heart  Poisons. — The  majority  of  the  arrow  poisons  used  by  Africans  and 
Asiatics  at  the  present  time  act  like  digitalin  ami  helleborin,  and  cause  death 
by  sudden  stoppage  of  the  heart  muscle.     Observations  on  French  soldiers  in 


22  WOUNDS 

the  Soudan  wounded  by  poisoned  arrows  of  the  Bambara  tribe  of  savages, 
showed  that  death  might  occur  in  from  eleven  to  thirteen  minutes.  Such 
poisons  are,  among  others,  the  "  Inee,"  "  Kombe,"  "  Wabain,"  "  Antiacin." 
To  the  heart  poisons  belong  also  those  used  by  the  Choco  Indians  of  New 
Granada,  made  from  the  skin  secretions  of  a  toadlike  creature,  Phyllobates 
melanorrhinus. 

II.  Heart  Poisons  with  an  Action  on  the  Nervous  Centers. — Various  African 
arrow  poisons  contain  one  or  several  substances  which  act  partly  on  the  heart, 
causing  spasm  or  paralysis  of  the  heart  muscle;  also  as  powerful  stimulants 
of  reflex  action  in  the  cord,  causing  tetanic  convulsions.  In  German  southwest 
Africa,  along  the  coast,  the  Owamba  tribe  use  a  poison  known  as  "  Echnja," 
prepared  from  a  plant,  "  Adonium  boehmianmn,"  which  produces  this  com- 
bination of  symptoms,  due  to  the  presence  of  a  glucoside,  "  Echnjin." 

III.  Purely  Tetanic  Poisons. — The  Pongahns  of  Malacca  and  the  natives 
of  Borneo  use  the  juice  of  various  species  of  Upas  to  prepare  a  poison  which 
produces  general  tetanic  convulsions,  and  causes  death  in  ten  or  fifteen  minutes 
from  asphyxia  from  tetanic  contraction  of  the  muscles  of  respiration. 

IV.  Poisons  Affecting  the  Respiration  Center  in  the  Medulla. — Such  are 
arrow  poisons  containing  the  aconite  bases,  aconitoxin  and  pseudo-aconitin, 
made  chiefly  from  the  plant  "  Aconitum  ferox,"  and  used  by  people  in  eastern 
Asia. 

V.  Poisons  Causing  General  Paralytic  Symptoms. — Of  these,  "  curare,"  used 
by  South  American  Indian  tribes,  is  the  best  known.  It  causes  paralysis  of 
the  voluntary  muscles  throughout  the  body.  Its  symptoms  are  familiar  to 
anyone  who  has  ever  worked  in  a  physiological  laboratory. 

VI.  Septic  Poisons. — Putrid  flesh,  heart  muscle,  liver,  etc.,  of  animals  dead 
of  rattlesnake  poison,  or  such  material  mixed  with  rattlesnake  venom,  were 
formerly  used  by  the  Indian  tribes  on  the  border  between  the  United  States 
and  Mexico.  Similar  poisons  are  prepared  by  the  African  bushmen  of  the 
Kalahazi  Desert  from  the  body  juices  of  the  chrysalis  of  a  beetle — Diamphi- 
dium  simplex.  These  poisons  do  not  act  immediately,  but  produce  a  local 
hemorrhagic  inflammation,  with  diarrhea,  hemoglobinuria,  collapse,  and  death 
in  two  or  three  days. 

VII.  Irritating  Poisons. — The  Moquis  Indians  of  Arizona  used  a  poison 
on  their  arrows  made  from  the  bodies  of  bumblebees.  Other  tribes  have  used 
the  milky  juice  of  Euphorbia  arborescens.  These  are  purely  irritating  sub- 
stances, and  produce  merely  an  exceedingly  painful  wound,  without  any  specific 
poisonous  effects. 

The  Bites  and   Stings   of  Insects 

Insects  of  various  kinds,  by  stinging  or  biting,  produce  poisonous  wounds. 
The  results  of  such  wounds  are  annoying,  but  not  serious,  unless  a  large  num- 
ber of  bites  are  received.     There  are  undoubted  cases  upon  record  of  death 


GUNSH01     WOUNDS 

following  innumerable  stings  from  wasps,  bees,  and  hornets,  and  intoxicated 
persons  have  *  I  i< « I  after  being  exposed  for  hours  t<>  the  bites  of  innumerable 
mosquitoes.  The  sting  of  the  scorpion  and  the  bite  of  the  tarantula  are  espe- 
cially poisonous,  and  much  dreaded.  The  effects  resemble  in  a  mild  form 
the  bites  of  Berpents;  they  are  rarely,  if  ever,  i';it;tl  to  human  beings.  The 
symptoms  caused  by  the  stings  of  bees,  horni  ts,  and  wasps  consisl  "t"  local  pain 
of  ;in  aching  or  burning  character.  A  tender  red  wheal  forms  almosl  al  once, 
an<I  remains  for  some  hours.  Tin-  sting  is  sometimes  left  in  the  wound,  :ni<l 
may  pi--. Ion-  the  irritation.  ]t  may  be  searched  for  and  extracted  with  the 
aid  of  a  magnifying  glass  and  ;i  fine  pair  of  forceps.  Bedbugs,  fleas,  and  body 
lice  produce  an  urticarial  eruption  characterized  by  intense  itching  and  burn- 
ing, which  usually  subsides  in  a  few  hours,  or,  in  sensitive  persons,  may  recur, 
on  mechanical  irritation,  for  Beveral  days.  Flea  bites  can  usually  be  distin- 
guished by  the  presence  of  a  minute  punctate  hemorrhage  in  the  skin,  which 
can  be  seen  in  the  center  of  the  wheal.  The  bodies  of  those  afflicted  for  long 
periods  by  body  lice  are  covered  with  scratch  marks,  and  after  a  time  pigment 
is  deposited  in  the  skin,  notably  on  the  breast,  the  flanks,  the  abdomen,  upper 
arm,  and  thighs.     The  appearance  is  characteristic. 

The  stings  and  bites  of  insects  have  acquired  an  entirely  new  and  impor- 
tant interest  during  recenl  years,  since  observation  and  experiment  have  shown 
thai  certain  infections  diseases  are  transmitted  to  man  in  this  way.  Among 
tin-  insects  capable  of  transmitting  disease  by  bites  are  mosquitoes.  The  vari- 
eties of  Anopheles  transmit  malaria;  Stegomyia  fasciata,  yellow  fever;  Culex 
pipiens,  filariasis.  It  is  probable  that  dengue  is  also  transmitted  by  a  mosquito. 
Fleas  arc  believed  to  transmit  bubonic  plague  from  one  rat  to  another,  or 
from  rat  to  man,  or  from  man  to  man.  Ticks  art'  believed  to  transmit  certain 
febrile  diseases  in  Asia  and  Africa;  also  probably  the  so-called  "spotted  fever" 
observed  in  the  Hitter  Root  Valley  of  the  Rocky  Mountains.  The  bites  of  bed- 
bugs are  believed  to  play  an  important  part  in  the  transmission  of  relapsing 
fever.  Lice  may  convey  impetigo  contagiosa.  In  addition  to  bites,  flies  and 
other  insects  transmit  bacterial  diseases  by  carrying  the  germs  of  typhoid 
fever,  erysipelas,  anthrax,  etc.,  on  their  bodies,  or  in  their  alimentary  canals, 
and  depositing  such  ii'crms  in  wounds,  in  food,  water,  etc. 

GUNSHOT    WOUNDS 

Gunshot  wounds  are  those  produced  by  the  discharge  of  firearms.  For 
purposes  of  diagnostic  description  they  may  he  divided  into  four  groups:  I. 
Those  caused  by  modern  military  rifles  and  pistols  of  a  caliber  varying  between 
7  and  8  mm.  II.  Wounds  produced  by  rifles  and  pistols  firing  a  -oft  leaden 
bullet  by  moans  of  a  charge  of  ordinary  black  gunpowder  and  having  a  caliber 
varying  from  0.22  inch  to  0.45  inch  or  more.  III.  Wounds  produced  by  shot- 
guns loaded  with  many  pellets  of  leaden  shol  of  various  sizes.  IV.  Wounds 
produced  by  artillery  projectiles.     It   has  been  considered  desirable  to  divide 


24 


WOUNDS 


gunshot  "wounds  into  these  several  classes,  because  the  character  of  the  wounds 
produced  by  these  various  weapons  differ  in  certain  important  details.     The 


Fig.  2. — Gunshot  Fracture  of  the  Radius  with  Extensive  Loss  of  Substance  Produced  by 
Soft  Lead  Rifle  Bullet,  Showing  Fragments  of  Lead  Embedded  in  the  Tissues.  The  X-ray 
picture  was  taken  nearly  a  year  after  the  injury.  An  attempt  to  improve  the  condition  by  re- 
section of  the  ulna  and  freshening  the  ends  of  the  radius  followed  by  suture  of  the  bone  was  followed 
by  nonunion  in  the  radius  and  delayed  union  in  the  ulna.  The  functional  result  so  long  as  the 
patient  wore  a  supporting  apparatus  on  the  forearm  was  good.      (Author's  case.) 

majority  of  gunshot  wounds,  however  produced,  partake  of  the  character  of 
punctured  wounds,  and  most  of  them  also  of  wounds  of  the  contused  and 
lacerated  varietv. 


I.  Wounds  Produced  by  Modern  Military  Rifles  and  Pistols 

The  explosive  used  is  one  or  other  of  the  varieties  of  smokeless  powder. 
The  bullet  is  of  very  small  diameter  compared  with  its  length,  and  consists 
usually  of  a  core  of  hardened  lead  surrounded  by  a  covering  or  jacket  of  a 
much  harder  material,  consisting  in  many  instances  of  a  thin  capsule  of  an 
alloy  composed  of  copper  and  nickel  or  of  copper,  nickel,  and  steel.  The 
point  of  the  bullet  is  rounded  or  oval  in  shape.  These  weapons  possess  in 
their  effects  certain  characters  which  distinguish  them  quite  sharply  from  the 
old-fashioned  rifles  and  pistols  firing  soft  lead  bullets.  In  the  first  place,  the 
velocity  of  the  projectile  as  it  leaves  the  muzzle  of  the  weapon  is  very  great, 
and  varies  between  600  and  720  meters  per  second,  as  compared  with  300  or 
400  meters  per  second  in  the  old-fashioned  rifles  firing  a  soft  lead  bullet 
with  a  charge  of  black  powder.  Moreover,  the  striking  energy  as  compared 
with  the  older  weapons  is  enormous.  The  range  is  also  greatly  increased. 
The  effective  range  of  the  old-fashioned  muzzle-loading  rifle — of  about  17 
mm.  caliber  and  a  soft  lead  bullet — varied  between  600  to  1,000  meters. 

The  Effective  Range. — The  range  of  the  modern  rifle  is  3,000  or  4,000 
meters,  or  even  more.  The  trajectory  of  these  modern  rifles  is  also  very  flat, 
that  is  to  say,  the  bullet  travels  so  fast  during  the  early  seconds  of  its  flight 
that  it  falls  but  little  in  iroing  a  Ions:  distance,  hence  much  less  allowance  is 


GUNSHCH     WOUNDS 


25 


necessary  for  distance  in  aiming,  and  within  certain  limits  bite  are  therefore 
much  more  frequent.  Owing  to  the  greal  momentum,  the  bullets  al  ordinary 
ranges  Beldom  lodge  within  the  body,  bu1  pass  directly  through  in  a  Btraighl 
line  without  reference  to  the  structures  encountered,  whether  soft  j >:i rt -  or 
bones.  Owing  t<>  the  hardness  of  the  bullet,  it  does  qoI  undergo  deformity 
when  striking  bones,  dot  is  it  ordinarily  deflected  from  its  cour 


Fig.  3^.  Fig.  36. 

Figs.  '■'•<!  and  36.  —  Fracture  op  tiik  Astragalus  Produced  by  a  Thirty-eight!  Caliber  Pistol 
Bullet  wun  Lodgment.  Antero-posterior  and  lateral  views  showing  track  of  bullet  through 
the  bone  and  bullel  in  situ.     (New  York  Hospital  collection.) 


Ricochet,  and  its  Deforming  Effect  upon  Bullets. — An  exception  to  this  rule 
occurs  when,  before  striking  the  body,  the  bullel  comes  into  contact  with  the 
ground  <»r  with  a  rock,  when  it  may  undergo  deformity  of  any  degree.  The 
most  common   deformity   noted   is   that   the  bullet    is   somewhal    bent   or   flat- 


26 


WOUNDS 


tened  at  its  point,  or  the  deformity  may  be  still  greater;  the  bullet  may  be 
twisted  quite  out  of  shape,  or  the  mantle  or  jacket  may  be  split  along  one  or 
more  lines — commonly  more  or  less  parallel  with  the  long  axis  of  the  bullet — 
and  the  leaden  core  may  be  thus  exposed  or  even  separated  from  its  mantle, 


Fig.  4a. 


Fig.  4b. 


Figs.  4a  and  4b. — Gunshot  Fracture  of  the  Upper  End  of  the  Radius.  Thirty-two  caliber  pistol 
bullet  showing  fragments  of  lead  and  bullet  slightly  deformed  lodged  in  the  soft  part  above  the 
elbow  and  in  front  of  the  humerus.     (New  York  Hospital  collection.) 


and  the  axis  of  the  bullet  may  assume  any  angle  in  reference  to  its  line  of 
flight;  whereas  under  ordinary  circumstances  the  two  are  parallel.  Bullets 
thus  deformed  produce  a  different  type  of  injury. 

If,  as  in  the  case  with  sporting  rifles  and  certain  pistols,  the  mantle  of 
the  bullet  is  left  incomplete  in  front,  exposing  the  lead  core  to  a  greater  or 
less  extent,  constituting  what  is  known  in  sporting  parlance  as  a  "  soft-nosed  " 


GUNSHOT    WOUNDS  27 

bullet,  or  if  the  mantle  near  the  poinl  of  the  bullel  be  Bawed,  filed,  or  split 
in  such  a  manner  thai  its  continuity  la  destroyed  or  its  strength  near  tii<'  point 
greatly  impaired,  then  the  bullel  when  ii  strikes  ;i  bone  or  even  the  sofl  parta 
may  undergo  greal  deformity.  Ii  may  be  extensively  Battened  near  the  ii|» 
— into  the  shape  "I  a  mushroom — or,  indeed,  broken  up  into  many  small 
fragments;  and  the  injuries  produced  by  such  bullets  are  of  greater  sever- 
ity than  the  wounds  caused  by  the  bullel  with  a  complete  mantle  and 
undeformed. 

Perforation  and  Lodgment. — The  small  calibered  steel-mantled  military  bul- 
lel produces  al  ordinary  ranges,  as  stated,  perforating  wound-.  Thai  is  to 
say,  the  bullel  pusses  entirely  through  the  body,  no  matter  in  whal  situation 
or  direction  the  wound  may  be  received.  This  is  of  course  true  only  up  to  a 
certain  range,  and  after  this  range  is  passed — which  varies,  of  course,  for 
different  regions  of  the  body — a  certain  number  of  Indicts  will  fail  to  pass 
completely  through  and  lodge  in  the  tissues.  Lodgmeul  of  the  bullel  will  also 
occur  with  considerable  frequency  at  all  ranges  when  the  bullel  strikes  the 
ground  or  some  hard  object  before  producing  the  wound.  Al  a  range  up  to 
1,600  or  even  2,000  meters  the  Indict  will  usually  perforate,  unless  it  has 
previously  struck  the  ground  or  impinges  upon  a  dense  large  hone. 

In  discussing  the  diagnosis  of  wounds  made  by  these  bullets,  ii  is  necessary 
to  consider  the  character  of  (he  tissues  through  which  the  bullet  passes,  and 
the  range  al  which  the  shol  was  fired,  that  is  to  say — other  things  being  equal 
— the  velocity  of  the  bullet  It  has  been  found  by  practical  experience  that 
the  effects  of  these  bullets  upon  the  tissues  vary  not  only  with  the  character 
of  the  tissue,  but  also  with  the  range.  Shots  fired  within  the  range  of  500 
meters  may  be  regarded  as  short  range,  shot-  from  500  to  L,200  meters 
medium  range,  and  from  1,200  meters  upward,  to  the  extreme  range  of  the 
weapon,  long  range. 

Effects  upon  Various  Tissues. — In  the  ordinary  sofl    tissues,    the  skin,   the 

fat,  fibrous  tissues,  fascia,  muscles,  thin  and  spongy  hones,  |>| l-vessels,  nerves, 

the  lungs,  these  hnllets — at  all  ranges  ii])  to  2,000  meters,  as  stated  by  various 
observers — make  a  clean  perforation  through  the  body  in  a  straighl  line.  The 
openings  where  the  bullel  enters  and  where  it  makes  its  exit  arc  often  quite 
similar  in   character.      They  consist    of  small    rounded   openings   of   the   size   of 

or  even  smaller  than  the  diameter  of  the  bullet.  At  short  ranges  the  wound 
of  exit  may  be  stellate,  angular,  or  slitlike,  and  larger  than   the  wound  of 

entrance;  this  is  not,  however,  constant,  The  tissues  in  the  track  of  the 
bullel  are  pulpified,  hut  there  is  vwy  little  laceration  except  in  the  immediate 
path  of  the  missile.  The  path  of  the  bullet  through  the  tendon-,  fascia?,  and 
aponeuroses  may  he  a  small  round  hole  or  a  mere  slit.  Blood-vessels  and  nerve- 
may  he  cleanly  perforated  or  partly  or  wholly  divided;  hut  they  seldom  esca]>e 
injury  by  being  pushed  aside,  as  is  the  ease  with  soft  lead  bullets  tired  at  low 
velocities.  If  the  hullet  Strikes  the  skin  obliquely  it  may  produce  a  slii  of 
some  length  or  an  oval  perforation  of  variable  size.     The  spongy    portion-  of 


28  WOUNDS 

the  long  bones,  if  struck  squarely,  are  frequently  cleanly  perforated,  as  though 
with  a  drill,  very  little  lateral  destructive  effect  being  observed. 

Explosive  Effect. — At  all  but  long  ranges,  where  the  velocity  of  the  bullet 
is  considerably  diminished,  there  is  observed  an  effect  upon  certain  tissues  and 
organs  which  lias  been  characterized  by  the  above  title.  This  effect  is  observed 
in  penetrating  wounds  of  the  skull ;  in  the  shafts  of  the  long  bones ;  in  the  solid 
glandular  organs  of  the  abdomen;  in  the  hollow  organs  of  the  abdomen,  when 
filled  with  fluid  or  saturated  with  fluid,  and  under  certain  other  conditions  to 
be  noted.  This  so-called  "  explosive  effect  "  is  of  a  most  destructive  character 
and  depends  upon  two  causes: 

The  first  cause  is  that  which  is  well  exemplified  by  the  often-tried  experi- 
ment of  firing  a  rifle  into  an  open  barrel  of  water  or  into  a  tin  can  filled  with 
water.  If  the  barrel  or  can  be  empty,  the  bullet  will  pass  through,  making  a 
clean  perforation,  but  without,  other  damage.  If,  however,  the  barrel  or  can 
be  filled  with  water,  even  if  open  at  the  top,  and  the  shot  fired  vertically  down- 
ward, the  barrel  or  can  will  be  burst  more  or  less  extensively.  Water  is  inelas- 
tic, and  has  no  time  to  change  its  level  and  adapt  itself  to  the  new  conditions 
of  pressure ;  accordingly,  it  forces  out  the  sides  of  and  bursts  the  containing 
vessel.     The  same  action  takes  place  in  wounds  of  the  skull,   etc. 

Under  these  conditions  the  wound  in  the  skull,  for  example,  may  be  a  small 
round  hole  as  large  as  the  diameter  of  the  bullet.  Upon  the  opposite  side  of 
the  head,  however,  the  skull  will  be  burst  outward,  with  extensive  comminu- 
tion of  bone,  and  the  projection  of  fragments  of  skull  for  a  distance  of  several 
feet,  with  the  production  of  a  large  ragged  wound  of  exit ;  or  the  skull  may 
not  be  actually  burst  into  fragments,  but  yet  be  extensively  fractured  and 
fissured,  the  fissures  running  downward  to  the  base.  .The  liver  may  be  very 
extensively  lacerated  and  pulpified,  the  kidney  the  same,  and  the  bladder, 
stomach,  and  intestines,  if  full  of  fluid,  may  be  extensively  burst  and  torn 
in  all  directions.  If  the  bullet  strike  the  hard  unyielding  shaft  of  a  long  bone, 
the  bone  may  be  pulpified  for  a  large  area  around  the  point  of  impact,  and 
fissures  may  extend  in  all  directions  up  and  down  the  shaft.  The  wound  of 
exit  in  such  cases  may  be  very  large  and  ragged. 

The  second  cause  for  this  explosive  action  is  that  the  fragments  of  bone 
and  other  tissues  thus  set  into  violent  commotion  become  secondary  missiles, 
and  cause  laceration  of  the  surrounding  parts  more  or  less  extensive.  Such 
wounds  as  these,  if  of  the  head,  are  usually  instantly  fatal,  and  do  not  come 
under  treatment.  If  of  the  abdomen,  they  will  usually  be  attended  by  such 
severe  shock  that  little  can  be  done  for  them.  If  of  the  extremities,  the  most 
varied  lesions  may  be  produced  both  in  the  bones  and  soft  parts.  The  diag- 
nosis of  some  of  these  varieties  of  wounds  produced  by  the  small-calibered  rifle 
will  be  discussed  under  wounds  of  regions.  If  the  range  is  greater  than  1,000 
meters  these  very  destructive  effects  upon  the  brain,  upon  the  large  glandular 
organs  of  the  abdomen,  and  upon  organs  containing  fluid,  gradually  diminish 
as  the  velocity  of  the  bullet  decreases,  and  finally  disappear.     In  a  general  way 


GUNSHOT    WOUNDS  29 

ii  may  be  said  thai  the  shorter  the  range,  the  more  marked  will  be  this  ex]  I 
effect. 

Hemorrhage  in  Gunshot  Wounds. —  In  wounds  which  involve  merelj 
parts  ;ni«l  do  not  penetrate  any  highly  vascular  organ,  and  injure  ii"  large 
blood-vessel,  hemorrhage  is  usually  slight  or  almosl  absent.  It.  however,  a 
large  arterial  or  venous  trunk  lies  in  the  path  of  the  bullet,  hemorrhage  of  a 
serious  or  fatal  character  is  rather  more  ap1  to  occur  than  i-  the  case  with 
the  large  caliber  sofl  lead  bullel  fired  ;it  low  velocity,  because,  as  already  stated, 
if  the  shol  be  ;i  direcl  one,  the  small-ealibered  bullel  pushes  nothing  aside, 
Inii  cuts  a  clean  track  in  a  straighl  line  through  the  tissues.  In  cases  where 
large  vessels  are  wounded-  such  as  the  femoral,  one  of  the  larger  arteries  <>\  the 
abdomen,  or  the  carotid—  ii  does  qoI  usually  happen  thai  the  patienl  comes 
under  surgical  treatment  a1  all  if  the  wound  be  inflicted  upon  ili«'  battlefield. 
Wounds  of  the  abdomen  which  injure  the  aorta,  the  vena  cava,  or  one  of  the 
larger  arteries  of  the  mesentery,  are  peculiarly  dangerous  from  hemorrhage,  as 
also  wounds  of  the  thorax  which  injure  one  of  the  large  vessels  ;M  the  rool 
of  the  lung.  On  the  other  hand,  wounds  of  tliis  very  serious  nature  rarely 
come  into  the  hands  of  the  surgeon  for  treatment,  and  actual  experience  in 
time  of  war  has  shown  thai  those  bullets,  if  undeformed,  may  pass  through 
the  human  body  in  the  mosl  varied  manner,  producing  only  temporary  and 
comparal  ively  slighl  injuries. 

Topography  of  Bullet  Wounds. — The  position  assumed  by  soldiers  upon  the 
firing  line  in  battle  is  usually  prone  upon  the  ground.  As  a  consequence,  many 
wounds  are  produced  which  puss  through  the  body  from  above  downward  or 
obliquely,  and  the  wound  canal  is  often  very  long,  and  may  traverse  the  entire 
trunk,  entering  in  the  supraclavicular  region  or  in  the  hack,  or,  as  often  hap- 
pens, passing  through  the  shoulder  first,  or  the  upper  extremity,  and  emerging 
from  the  buttock,  or  from  the  groin,  or  from  the  thigh,  without  producing  a 
fatal  injury.  Wounds  of  the  thorax  also,  which  penetrate  the  lung,  are  fre- 
quently recovered  from  easily,  and  with  Utile  or  no  permanent  disability. 
Wounds  of  the  larger  joints,  such  as  the  knee,  the  shoulder,  and  the  ankle, 
often  heal  rapidly  and  without  any  permanent  loss  of  function.  Even  wounds 
ef  the  diaphragm — although  attended  at  the  time  by  shock,  by  rapid,  -hallow, 
and  difficull  respiration,  and  accompanied  by  some  dyspnea,  and  by  the  accu- 
mulation of  a  moderate  quantity  of  Mood  in  the  pleural  cavity — often  gel  well 
without  any  serious  permanent  results. 

Aseptic  Healing. — During  the  war  in  Cuba,  during  the  fighting  in  the  Phil- 
ippines, during  the  war  in  South  Africa,  and  in  the  Russian- Japanese  War  it 
was  noted  in  hundreds  of  cases  that  such  wounds  were  recovered  from,  with 
little  or  no  treatment,  except  an  external  protective  dressing,  without  perma- 
nent disability.  'These  facts  are  to  l>o  accounted  for  upon  several  grounds. 
In  the  lirst  plaee,  a  large  proportion  of  the  wounds  are,  as  stated,  perforating 
wounds.  There  has  keen,  therefore,  no  occasion  or  excuse  for  the  commonly 
dangerous  and  useless  procedure  of  probing  a  wound  with  a  dirty  instrumenl 


30  WOUNDS 

and  unclean  fingers  to  the  detriment  of  the  patient.  Secondly,  as  already  indi- 
cated, many  of  these  wounds  are  either  fatal  before  any  medical  aid  is  possi- 
ble, or  else  involve  no  necessarily  lethal  injury.  Thirdly,  the  shape  and  the 
small  size  of  these  bullets,  and  the  fact  that  they  perforate  and  do  not  lodge, 
diminishes  the  chances  of  infectious  material  in  considerable  quantity  being- 
carried  into  and  remaining  in  the  wound. 

It  has  been  found  by  experience  that  many  of  these  wounds,  if  untreated, 
heal  by  primary  union.  The  edges  of  the  slightly  contused  orifices  become 
brownish  in  color,  dry,  and  are  soon  covered  with  a  small  adherent  scab.  Occa- 
sionally slight  infection  of  one  or  other  orifices  takes  place,  but  does  not 
usually  extend  to  the  deeper  portions  of  the  wound.  Careful  inspection  of 
the  wound  tracks  often  show  that  when  the  bullet  has  passed  through  the  cloth- 
ing small  shreds  of  cloth  and  the  like  may  be  scattered  along  the  course  of  the 
wound,  but  they  do  not  appear  to  cause  infection  in  many  instances.  Wounds 
of  the  skull  through  the  scalp  are  usually  found  to  contain  fragments  of  hair 
and  often  particles  of  bone,  which  may  be  driven  deeply  into  the  brain  or  lie 
upon  its  surface  or  upon  the  dura.  These  fragments  are  often  derived  from 
the  internal  table,  which  is  sometimes  extensively  splintered. 

Straight  Path  of  High-powered  Bullets. — The  diagnosis  of  the  structures 
injured  by  these  bullets  is  often  much  easier  than  was  the  case  with  the  soft 
lead  missile,  for,  in  general,  they  pass  through  the  body  in  a  straight  line, 
and  the  structures  wounded  can  usually  be  inferred  on  anatomical  grounds. 
If  fractures  exist,  they  will  give  the  ordinary  signs  of  fracture,  unless  the 
bone  is  merely  perforated.  Wounds  of  organs  will  give  characteristic  signs 
and  symptoms.  Wounds  of  the  belly  will  be  considered  under  the  surgery 
of  that  region.  When  the  range  is  very  great,  perforating  wounds  will, cease 
to  be  the  rule,  and  lodgment  of  the  bullet  will  be  more  common.  At  very 
great  ranges  also  the  so-called  "  explosive  effect "  is  absent.  The  bullet  does 
not  exercise  the  same  destructive  force  laterally  as  occurs  when  the  missile 
is  moving  at  higher  velocity.  The  prognosis,  then,  of  such  wounds  when  they 
involve  the  brain,  the  glandular  organs  of  the  abdomen,  or  the  hollow  abdominal 
viscera,  is  not  so  serious.  The  injuries  come  to  resemble  those  produced  by 
an  undeformed  leaden  bullet  moving  at  a  low  velocity. 

Lodgment  of  the  bullet  may,  of  course,  be  inferred  from  the  absence  of  a 
wound  of  exit.  The  practical  importance  of  the  continued  presence  of  such 
a  bullet  in  the  tissues  is  not  very  great  in  the  average  case.  It  is  only  when 
the  bullet  causes  pain,  etc.,  by  pressure  on  a  nerve  trunk  or  the  wound  has 
become  infected  and  a  suppurating  tract  remains  in  the  tissues,  with  the  bullet 
lying  at  the  bottom  thereof — as,  for  examrjle,  among  the  fragments  of  a  frac- 
tured bone,  or  in  the  interior  of  the  skull,  with  threatened  abscess  of  the  brain 
or  symptoms  of  cerebral  irritation — that  the  location  of  the  bullet,  and  its 
subsequent  extraction,  become  matters  for  the  consideration  of  the  surgeon. 
And  even  in  these  cases  it  is  sometimes  a  question  whether  the  operative  re- 
moval of  such  a  bullet  is  justifiable  or  desirable.     The  usual  indications  are, 


GUNSHOT    WOUNDS  :;] 

however,  when  a  bullel  ia  Lodged  in  an  infected  wound  proper  drainage  of  the 
wound,  the  extraction  of  foreign  bodies,  such  as  portions  of  clothing  or  frag- 
ments "I  dead  bone,  ami  removal  of  the  bullet  if   fairly  accessible. 

Effects  of  Lodgment.— Long  experience  lias  shown  thai  the  mere  presence 
of  a  portion  of  or  the  whole  of  a  bullet  in  the  tissues  is  seldom  productive 
of  deleterious  effects.     In  some  cases  of  bullel  wound  of  the  brain  or  of  the 

spinal  canal  or  in  those  cases  where  a  bullet  appears  to  he  producing  paraly-i- 
or  irritation,  hv  pressure  upon  a  nerve  trunk,  the  location  of  a  bullel  may. 
however,  become  a  matter  of  practical  importance.  For  Locating  such  bullets 
no  means  hitherto  devised  compares  favorably  in  simplicity,  accuracy,  aid 
safety  with  the  use  of  the  X-rays.  The  well-known  dangers  of  introducing 
a  prohe  or  other  similar  instrument  into  a  fresh  or  ancient  wound  applies  here 
with  peculiar  force.  It  is  well  known  that  the  walls  of  a  granulating  wound 
are  almost;  invulnerable  to  the  inroads  of  the  pyogenic  bacteria,  so  long  as  the 
granulations  are  not  mechanically  injured.  Probing  a  wound  or  introducing 
any  instrument  for  diagnostic  purposes — unless  such  an  exploration  i-  fol- 
lowed immediately  by  an  operation  which  converts  the  wound  canal  into  a 
simple  and  widely  opened  cavity — unavoidably  injures  the  granulating  sur- 
face, and  renders  infection  with  the  pyogenic  microbes  not  only  possible,  but 
probable,  and  it  has  come  to  be  a  well-recognized  fact  among  surgeons  that 
such  infection  frequently  takes  place,  with  serious,  if  not  fatal,  consequences 
to  the  unfortunate  patient. 

The  X-rays,  on  the  other  hand,  when  used  with  intelligence,  permit  one  to 
locate  Indicts  with  considerable  accuracy,  even  when  rather  deeply  placed  in 
the  tissues,  and  that  without  any  especially  elaborate  apparatus.  The  propor- 
tion of  lodged  small-caliber  bullets  has  been  found  in  actual  warfare  to  be 
unexpectedly  high.  Of  198  wounds  from  Mauser  bullets  coming  under  treat- 
ment in  the  Santiago  campaign,  there  were  21  lodged  bullets.  Many  of  these 
bullets  were  found  by  X-ray  examination  undeformed  or  but  slightly  deformed. 
It  is  presumed  that  the  absence  of  deformity  depends  rather  upon  the  hard- 
ness of  the  bullet  than  upon  the  fact  that  the  velocity  of  the  bullet  had  been 
reduced  by  a  very  long  flight  The  nature  of  the  ground  over  which  the 
fighting  was  done  indicated  rather  that  the  velocity  of  the  bullets  had  been 
reduced  by  striking  the  limits  of  trees  or  other  objects.  The  methods  of  detect- 
ing and  locating  bullets  and  other  foreign  bodies  are  described  in  the  chapter 
X-rays  in  Surgical   Diagnosis. 

Effects  of  Ricochet. — When  military  bullets  are  greatly  deformed  by  rico- 
chet ami  lodge  in  the  tissues,  they  may  or  may  not  produce  wounds  showing 
great  Laceration  of  tissue.  In  many  instances  the  wound  will  not  vary  in 
appearance  from  the  ordinary  small-caliber  Indict  wounds — notably  if  the 
bullet  is  merely  blunted  and  strikes  the  tissues  with  its  long  axis  perpendicular 
to  the  surface  either  point  foremost  or  butl  end  foremost.  If.  on  the  other 
hand,  the  bullet  after  the  ricochet  assumes  a  rotation  upon  an  axi<  transverse 
to  its  long  axis,  the  wound  of  the  skin  may  he  of  considerable  size,  and  the 


32  WOUNDS 

deeper  tissues  may  be  lacerated  to  a  greater  or  less  extent,  and  bones  may  also 
be  fractured  and  comminuted  more  or  less  extensively.  Under  these  condi- 
tions the  wound  may  resemble  such  wounds  as  are  made  by  the  bullet  from  a 
shrapnel  shell,  or  soft-lead  bullet,  or  a  shell  fragment ;  and  such  wounds  will, 
on  account  of  the  larger  wound  of  entrance  and  the  greater  laceration  of  the 
tissues,  be  more  likely  to  become  infected  from  external  sources.  Nevertheless, 
experience  shows  that  even  in  these  wounds  treatment  by  an  occlusive  dress- 
ing as  soon  as  may  be  and  noninterference  with  the  deeper  portions  of  the 
wound  are  attended  by  exceedingly  good  results,  infection  being  the  excep- 
tion rather  than  the  rule.  Certain  special  indications  for  the  location  of 
lodged  bullets  will  be  spoken  of  under  Kegional  Surgery.  It  has  been  found 
by  experience  that  these  deformed  bullets  usually  pursue  a  straight  course 
through  the  tissues. 

Wounds  Produced  by  High-powered  Rifles  of  Small  Caliber  Firing  a  Soft-nosed 
Bullet. — A  soft-nosed  bullet  is  one  in  which  the  hard  mantle  is  incomplete  in 
front,  the  point  being  composed  of  soft  lead,  or  in  which  the  mantle  is  filed, 
sawed,  or  split  at  its  point.  Such  bullets  are  commonly  used  in  shooting  large 
game,  sometimes  in  fighting  savage  peoples,  and  occasionally  by  savage  peoples 
themselves  when  firing  at  their  enemies.  They  are  variously  known  as  the 
soft-nosed  bullet,  the  Tweedie  bullet,  and  the  dumdum  bullet.  The  injuries 
produced  by  high-powered  rifles  firing  these  bullets  are  much  more  severe  than 
those  caused  by  the  ordinary  full-mantled  military  rifle  bullet. 

Upon  striking  bone,  or  even  the  denser  soft  parts,  these  bullets  undergo 
deformity  of  several  types.  The  most  common  change  in  shape  is  that  the 
soft  portion  of  the  bullet  in  front  is  flattened  and  spread  into  the  shape  of  a 
mushroom ;  or  upon  striking  hard  bone  the  bullet  may  be  disintegrated  into 
many  small  pieces,  each  one  of  which  becomes  a  missile  and  produces  its 
own  destructive  effect.  Fortunately,  wounds  from  these  bullets  are  rare  in 
warfare,  and  occur  for  the  most  part  as  the  result  of  accident,  by  the  acci- 
dental discharge  of  sporting  rifles  of  the  high-powered,  small-calibered  type,  or, 
as  happens  only  too  frequently,  when  an  excited  sportsman  mistakes  a  com- 
panion or  some  other  unfortunate  individual  for  a  wild  animal. 

Effects  of  Soft-nosed  Bullets. — The  wounds  produced  by  these  bullets  upon 
the  human  body  are  of  the  most  terribly  destructive  character.  At  short  and 
moderate  ranges  they  are  perforating.  At  longer  ranges  the  whole  or  a  portion 
of  the  bullet  may  lodge.  The  wTound  of  entrance  in  the  skin  does  not  differ 
from  those  wounds  produced  by  the  ordinary  military  bullet.  But  the  expan- 
sion or  disintegration  of  the  bullet  after  entering  the  body  produces  wounds 
of  the  most  destructive  character.  The  shape  of  the  wound  is  roughly  a  cone. 
The  apex  of  the  cone  is  at  the  point  of  entrance,  and  the  base  at  the  point  of 
exit,  or  wherever  the  bullet  ceases  to  produce  its  destructive  effect. 

The  tissues  in  the  track  of  such  a  bullet  are  churned  up  into  a  pulpified 
mass  of  entirely  disintegrated  tissues.  The  bones  are  also  extensively  fractured 
and  comminuted;  and,  secondarily,  lacerated  wounds  of  variable  size,  extent, 


GUNSHOT    WOUNDS 

and  shape  are  produced  by  the  fragments  separated  from  fli<'  body  of  the  missile. 
►Such  a  wound,  it'  of  the  head,  the  thorax,  or  the  abdomen,  produces  bo  de- 
structive  an  effecl  that  an  immediately  <>r  speedily  fatal  resull  is  the  pule.  If 
of  .'in  extremity  involving  bone  as  well  as  Bofl  parts,  the  disintegration  of  the 
tissues  is  commonly  so  greal  thai  no  treatmenl  other  than  amputation  can  be 
applied.  If  the  wound  involves  merely  the  sofl  parts  of  an  extremity,  exten- 
sive laceration  of  muscles,  vessels,  oerves,  and  integumenl  will  be  common. 
In  certain  instances,  however,  if  these  bullets  strike  merely  the  softer  tissues, 
they  may  doI  become  deformed,  and  may  pass  through  a  limb,  producing  the 
same  effecl  as  the  harder  military  bullet. 

Diagnosis. — The  diagnosis  of  injuries  produced  by  these  bullets  does  ool 
usually  present  any  difficulties,  the  main  factors  being  a  small  wound  of  en- 
trance, a  very  large  wound  of  exit,  and  very  extensive  laceration  and  puri- 
fication of  the  (issues  in  the  track  of  the  bullet,  whether  such  tissues  be  bones 
or  soft  parts.  On  account  of  the  great  destruction  of  tissue,  infection  of  greater 
or  less  gravity  is  almost  sure  to  occur. 

Wounds  Produced  by  Automatic  Pistols:  Tiik  Mauser  Pistol,  Caliber 
7.63  Millimeters.  The  Luger  Pistol,  Caliber  7.<»r>  Millimeters.  The 
Colt  Automatic  Pistols,  Caliber  .32  and  .38. — In  1897  Bruns  conducted 
experiments  with  the  Mauser  pistol,  and  concluded  that  the  effects  of  its  Indict 
were  identical  with  that  of  the  military  rifle  at  proportionately  longer  ranges. 
The  following  relations  were  found  to  exist:  At  20  to  200  meters  the  effect 
of  the  Mauser  pistol  was  the  same  as  the  effect  of  the  military  rifle  at  1,000 
to  2, (MM)  meters  respectively.  Tn  this  connection  I  insert  tlie  results  of  certain 
experiments  made  by  me  with  automatic  pistols  in  order  to  determine  the  effects 
of  smokeless  powder  at  short  ranges  upon  the  skin,  and  incidentally  to  ohserve 
the  effects  of  the  bullets  upon  the  tissues,  in  comparison  with  the  old-fashioned 
black-powder  revolver  firing  a  soft-lead  bullet  and  a  small  charge  of  black 
gunpowder. 

The  Effects  upon  the  Skin  of  Black  and  of  Smokeless  Powder  Fired  at  Short 
Ranges. — The  effects  upon  the  skin  produced  by  the  discharge  of  small  arms 
loaded  with  Mack  powder  and  tired  at  very  short  range  have  often  been  stud- 
ied. The  subject  is  of  especial  interest  from  a  medico-legal  point  of  view,  and 
occasionally  from  the  point  of  view  of  surgical  diagnosis.  Nol  all  the  grains 
of  black  powder  in  the  charge  are  burned  in  the  weapon  unless  the  charge  be 
unusually  small;  and  the  number  of  unburned  or  partly  burned  grains  will 
increase  with  the  size  of  the  powder  charge  and  the  caliber  of  the  weapon  and 
diminish  directly  with  the  length  of  the  barrel.  These  unburned  or  partly  burned 
grains  are  propelled  from  the  muzzle  with  considerable  force  for  a  distance  of 
several  feet.  If  these  grains  strike  the  human  skin  or  the  clothing,  certain 
effects  will  be  produced,  which  will  vary  according  to  the  caliber  of  the  weapon, 
the  size  of  the  powder  charge,  and  the  distance  of  the  muzzle  from  the  skin 
or  the  clothing,  as  the  case  may  be.  With  a  given  weapon  and  a  given  charge 
of  powder  it  may  be  possible  to  determine  from  the  character  of  these  effects 


34  WOUNDS 

whether  a  shot  has  been  fired  within  a  certain  distance  or  not.  The  important 
hearing  of  such  data  in  certain  cases  of  homicide  or  suicide  is  obvious;  and 
evidence  so  derived  has  been  of  great  use  in  many  instances  in  the  further- 
ance of  justice. 

The  Effects  Produced  by  Black  Powder  upon  the  Shin. — Powder  marks 
on  the  skin  are  in  the  nature  of  tattoo  marks- — that  is  to  say,  the  grains  of 
powder  are  driven  into  the  substance  of  the  skin,  and  leave  black  or  bluish 
marks  therein  which  are  practically  indelible.  The  area  thus  marked  increases 
with  the  distance  at  which  the  shot  was  fired,  whereas  the  number  of  grains 
embedded  diminishes  with  the  distance.  Such  tattooing  occurs  with  ordinary 
black-powder  revolvers  at  a  distance  of  at  least  three  or  four  feet;  and  such 
tattooing  has  been  produced  experimentally  with  a  .32-caliber  revolver  at  a 
distance  of  three  feet.  The  hair  of  the  scalp  may  be  singed  at  a  distance  of 
seven  or  eight  inches  by  such  a  revolver ;  clothing  may  be  scorched  at  a  similar 
distance ;  and  at  a  distance  of  one  foot  or  less  linen  may  be  set  on  fire. 

A  personal  communication  from  Dr.  Albert  L.  Hall,  of  Fulton,  1ST.  Y., 
who  has  conducted  a  large  number  of  experiments  with  pistols  loaded  with 
black  powder,  contains  some  of  the  results  of  his  observations.  They  are  here 
quoted  as  of  interest  and  value  from  a  medico-legal  point  of  view. 

Human  hair  can  be  singed  by  the  discharge  of  pistols  loaded  with  black 
powder  up  to  a  distance  of  twenty  inches,  probably  not  more.  Hair  can  be 
smoke-stained  at  about  twice  the  singeing  distance.  Some  of  Dr.  Hall's  obser- 
vations in  detail  were  as  follows: 

A  .30-caliber  Colt's  pistol  loaded  with  7  grains  of  black  powder  singed 
human  hair  up  to  5^  inches.  A  .32-caliber  Smith  &  Wesson  pistol,  10  grains 
of  black  powder,  88  grains  of  lead,  caused  singeing  at  7^  inches.  A  .44  auto- 
matic Colt's  pistol,  40  grains  of  black  powder,  217  grains  of  lead,  caused  singe- 
ing up  to  17  inches,  smoke-staining  up  to  3  feet.  A  .38  Colt's  army  pistol, 
singeing  occurred  up  to  12  inches.  With  a  .38  Smith  &  Wesson  pistol,  15 
grains  of  black  powder,  146  grains  of  lead,  hair  was  singed  up  to  10  inches. 

The  effects  of  black  powder,  then,  are  obvious,  and  within  certain  limits 
fairly  definite. 

The  Effects  Produced  upon  the  Shin  by  the  Discharge  of  Pistols  Loaded 
with  Smokeless  Powder. — The  effects  of  smokeless  powder  are  very  different. 
There  are  at  present  in  the  market  several  kinds  of  pistols  using  smokeless 
ammunition ;  it  seems,  therefore,  not  improbable  that  in  the  future  a  certain 
proportion  of  homicides  and  suicides  will  be  committed  with  weapons  using 
ammunition  of  this  class.  Smokeless  powders  have  guncotton  as  a  basis,  to 
which  is  sometimes  added  a  small  amount  of  nitroglycerin,  or  some  picric-acid 
compound,  or  one  or  more  of  a  number  of  ingredients  both  organic  and  inor- 
ganic. The  purpose  of  the  additions  is  to  modify  the  character  of  the  igni- 
tion, or  of  the  explosion,  or  to  give  the  powder  a  distinctive  color,  or  to  make 
it  waterproof.  The  grains  of  such  powders  are  usually  small  in  comparison 
with  the  grains  of  black  powder,  although  not  always.     The  explosion  of  black 


GUNSHOT    WOUNDS 

powder  gives  on  the  average  Bixty  five  per  cent,  by  weight,  of  Bolid  residue  and 
thirty-five  per  <-<-ii t.  of  gases.  Smokeless  powders  give,  on  the  other  band,  nearly 
seventy  per  cenl  of  gases  and  thirty  per  cenl  of  solid  residue.  Smokeless  pow- 
der is  at  leasl  twice  as  strong,  weight  for  weight,  as  black  powder,  and  some 
kinds  are  much  stronger;  accordingly,  the  amounl  oi  residue  "1  smokeless 
powder  driven  from  the  gun  is  much  less  than  that  of  black.  The  combustion 
of  smokeless  powder  is,   in  other  words,   much   more  complete. 

1  experimented  with  five  pistols-  Colt's  automatic  pistol,  caliber  .32;  Colt's 
automatic  pistol,  caliber  .38;  the  Luger  automatic  pistol,  caliber  7.65  mm.; 
the  Mauser  repeating  pistol,  caliber  7.63  mm.  For  comparison  a  black  powder 
.32-caliber  revolver  was  used,  made;  by  Hopkins  &  Allen,  firing  Smith  & 
Wesson  ammunition  and  Mack  powder.  For  the  purpose  of  testing  the  effects 
of  the  discharges  upon  the  skin  the  body  of  a  medium-sized  man  was  procured. 
The  cadaver  was  quite  recent,  the  skin  showed  no  signs  of  decomposition,  the 
muscles  were  quite  firm.  I  vigor  mortis  was  absent.  In  addition  to  notes  on 
the  effects  produced  upon  the  skin,  a  few  observations  were  made  on  the  pene- 
tration of  the  different  pistols,  and  a  number  of  shots  were  fired  al  pice-  of 
linen  cloth  and  at  a  piece  of  woolen  cloth.  Some  experiments  were  also  made 
with  a  shotgun  to  determine  the  effects  produced  a1  differenl  ranges.  The 
Bhotgun  was  a  12-gauge  Parker  gun,  what  is  known  as  a  close-shooting  gun. 

Shot  I.— Colt's  automatic  pistol,  caliber  .32;  charge,  4  grains  of  Walsrode 
powder;  Indict,  weight,  seventy-six  grains,  full  cupro-nickel  jacket;  distance  of 
muzzle  of  pistol  from  the  skin,  two  inches.  The  shot  was  fired  at  the  side  of  the 
head  in  front  of  the  ear,  skin  covered  with  short  hair.  The  hair  was  not  singed. 
The  skin  was  not  burned.  A  few  grains  of  a  dark  gray  residue  were  found  upon 
the  hair  and  upon  the  skin  over  an  area  one  inch  in  diameter  surrounding  the 
bullet  wound.  These  grains  were  readily  wiped  off  with  a  dry  cloth,  leaving  no 
visible  mark  behind.  The  wound  of  entrance  was  a  small  circular  orifice  one  six- 
teenth of  an  inch  in  diameter.  There  was  no  fraying  or  discoloration  of  the  edges. 
The  wound  at  the  point  of  entrance  in  the  skull  was  found  to  he  a  round  hole 
through  the  hone  about  the  diameter  of  the  bullet.  The  wound  of  exit  from  the 
scalp  upon  the  opposite  side  of  the  head,  hack  of  the  ear,  was  a  mere  slit  in  the 
skin  one  fourth  of  an  inch  in  length.  The  wound  of  exit  from  the  skull  was  a 
round  hole  about  the  diameter  of  the  bullet.  No  explosive  effeel  was  observed. 
The  bullet  struck,  but  failed  to  penetrate  a  barrel  of  sand  used  as  a  backing  and 
was  picked  up  slightly  flattened  at    the  point. 

Shot  II. — Colt's  automatic  pistol,  caliber  .38  of  an  inch;  eupro-niekel  jacket 
incomplete  in  front  (what  is  known  as  a  soft-nosed  bullet  )  ;  charge,  ~t  grains 
of  Walsrode  powder;  weight  of  bullet.  130  grains.  The  shot  was  fired  into  the 
temporal  region,  at  a  distance  of  two  inches.  Wound  of  entrance  was  a  round 
Orifice  in  the  skin  one  eighth  of  an  inch  in  diameter.  Edges  of  orifice  were 
Blightly  frayed.  There  were  a  few  faint  grayish  stains  upon  the  skin  surround- 
ing the  wound.     These  specks  appeared   to  he  embedded   in   the  skin,  and  could 

not  be  removed  with  a  wet  cloth.  The  hole  of  entrance  through  the  skull  was 
round  and  about  the  diameter  of  the  bullet.     The  wound  of  exit  in  the  skin  upon 


36 


WOUNDS 


the  opposite  side  of  the  head  was  an  irregular  tear  about  one  inch  in  length,  with 
radiating  slits  along  its  border.  Brain  substance  escaped  freely  from  this  orifice, 
as  well  as  from  the  external  auditory  canal  on  the  same  side  of  the  head.  Pal- 
pation of  the  skull  showed  a  comminuted  fracture  surrounding  the  wound  of  exit. 
The  comminution  of  the  skull  extended  over  an  area  three  inches  in  diameter 
in  the  temporal  and  parietal  regions.  There  was  also  evidently  present  a  fracture 
of  the  base  of  the  skull.  After  leaving  the  head  the  bullet  buried  itself  in  a  barrel 
of  sand.     The  explosive  effect  of  this  shot  was  well  marked. 

Shot  III. — For  purposes  of  comparison,  a  shot  was  fired  from  a  Hopkins  & 
Allen  revolver,  caliber  .32,  ten  grains  black  powder,  Smith  &  Wesson  ammunition, 


Fig.  5. — Photograph  of  the  Head  of  a  Male  Cadaver,  Showing  the  Wounds  of  Entrance  in 
the  Scalp  made  by  Pistols  Held  Close  to  but  not  in  Contact  with  the  Head.  The  shots 
Nos.  1,  2,  and  3  are  described  in  the  text. 

soft-lead  bullet.  The  shot  was  fired  into  the  temporal  region  with  the  muzzle 
of  the  pistol  three  inches  from  the  scalp.  The  hair  was  singed.  The  scalp  was 
burned  and  tattooed  with  powder  grains,  so  that  the  skin  was  blackened  over  an 
area  one  and  one  half  inches  in  diameter.  The  wound  of  entrance  in  the  skin 
was  one  eighth  of  an  inch  in  diameter,  the  edges  were  slightly  contused  and  stained 
with  lead.  The  hole  in  the  skull  was  about  the  diameter  of  the  bullet.  The  bullet 
lodged.  The  accompanying  illustration  is  a  .picture  of  these  three  shots.  From 
before  backward:  (1)  .32,  black  powder;  (2)  .38,  Colt,  smokeless;  (3)  .32,  Colt, 
smokeless. 


GUNSHOT    WOUNDS 

Shot  [V.— Luger  automatic  pistol;  steel-jacketed  bullet;  jacket  incomplete 
over  a  small  circular  area  al  the  poinl  of  bullet  where  the  lead  interior  is  exp 
distance,  three  inches.  Shot  was  fired  into  the  cheek  over  malar  bone  backward, 
downward,  and  inward.  No  powder  marks  were  upon  the  skin.  Orifice  of  entrance 
was  three  sixteenths  of  an  inch  in  diameter,  and  circular.  Edges  were  slightly 
contused  and  white  in  color.  No  tearing  of  tissues  nor  explosive  effect  was 
observed.     Bullel  was  extracted  lateT  undeformed. 

Shot  V.— Mauser  automatic  pistol;  caliber  7.63  mm.;  steel-jacketed  bullet; 
distance  of  muzzle  of  pistol  from  skin  Hirer  and  one  half  inches.  Shot  was  fired 
at  outer  aspecl  of  upper  third  of  right  thigh.  Powder  stain  was  one  inch  in  diam- 
eter, a  grayish  smudge  without  deposition  of  distinct  grains.  Wound  of  entrance 
was  circular.  Edges  were  slightly  frayed  and  contused,  white  in  color.  Wound 
of  exii  on  inner  surface  of  limb  was  oval,  three  sixteenths  of  an  inch  in  diameter, 
slightly  ragged.  There  was  wound  of  entrance  on  inner  aspecl  of  left  thigh; 
wound  of  exit  on  opposite  Bide  tin'  same.  The  bullet  then  passed  through  the  distal 
phalanx  of  left  thumb  and  entered  a  barrel  of  sand,  penetrating  a  distance  of  one 
lout.  Although  the  hullet  passed  through  the  center  of  both  Limbs,  neither  femur 
was  fractured,  nor  was  the  hullet  deformed. 

Shot  VI. —  Mauser  pistol;  fired  into  upper  third  of  right  thigh  at  a  distance 
of  one  foot;  full-jacketed  hullet.  A  few  dark-colored  specks  or  grains  were  present 
on  the  skin  around  the  wound  over  an  area  three  inches  in  diameter.  These  were 
readily  wiped  oft'  with  a  dry  cloth.  The  bullet  caused  a  fracture  of  the  right  femur, 
and  passed  across  the  body  above  the  perineum,  passed  through  the  pelvic  hone 
and  was  found  just  beneath  the  skin  above  the  left  great  trochanter.  The  Indict 
was  slightly  deformed. 

Shot  VII. — Hopkins  &  Allen  revolver,  black  powder.  .32  caliber.  Smith 
\  Wesson  ammunition.  Shot  was  fired  at  outer  aspect  of  right  thigh:  distance, 
one  foot.  Skin  was  tattooed  with  powder  marks  too  numerous  to  count  over  an 
area  three  and  one  half  inches  in  diameter.  Wound  of  entrance  was  circular, 
three  sixteenths  of  an  inch  in  diameter;  edges  stained  with  lead.     Bullet  lodged. 


Inasmuch  as  the  effects  of  smokeless  powder  upon  the  skin  were  found  to 
be  slight  even  at  very  (dose  range,  no  experiments  were  made  at  a  distance 
greater  than  one  foot.  The  only  shots  producing  stains  which  could  not  be 
wiped  away  were  the  Colt  pistol,  caliber  .38,  which  produced  a  small  and 
barely  perceptible  smudge  upon  the  seal])  at  a  distance  of  three  inches,  and 
the  Mauser  pistol,  which  produced  a  slightly  more  perceptible  smudge  at  the 
same  distance.  At  one  foot  none  of  the  smokeless-powder  pistols  left  any 
permanent  powder  marks  upon  the  skin. 

Photograph  Xo.  2  is  a  picture  of  two  shots  in  the  thigh  with  a  Mauser 
pistol  at  one  foot  and  three  and  one  half  inches,  respectively. 

Photograph  No.  3  is  a  picture  intended  to  show  the  contrast  between  the 
effect-  of  a  .'■'-  caliber  revolver  loaded  with  black  powder  and  the  Mauser 
pistol  loaded  with  smokeless  powder,  each  at  a  distance  of  one  foot.  The 
wounds  were  not  wiped  before  the  pictures  were  taken. 

A  number  of  shots  were  then  tind   with   portion-  of  a  linen  handkerchief 


38 


WOUNDS 


as  a  target.     A  piece  of  woolen  cloth  was  then  used,  and  then  some  squares 
of  cardboard.     The  distances  were  three  inches  and  one  foot. 

It  is  to  be  noted  that  the  smokeless  powders  produced  only  very  slight 
discoloration  of  the  linen  cloth  even  when  tired  at  a  distance  of  three  inches. 


Fig.  6  is  a  Photograph,  over  which  the  Label  Xo.  2  has  been  Pasted,  Showing  the  Wounds  of 
Entrance  of  Two  Pistol  Bullets.  To  the  right  is  shown  the  wound  of  entrance  made  by  the 
Mauser  automatic  pistol  at  a  distance  of  three  and  one-half  inches  from  the  skin  of  the  outer  sur- 
face of  the  right  thigh  (shot  Xo.  5  as  described  in  the  text).  The  slight  powder  stain  is  readily 
distinguishable.  On  the  left  is  the  wound  of  entrance  made  by  a  bullet  from  the  same  pistol  at  a 
distance  of  one  foot.  The  powder  stains  were  so  slight  that  they  do  not  show  in  the  photograph 
(shot  Xo.  6  as  described  in  the  text). 

Upon  woolen  cloth  no  effect  was  produced  appreciable  by  the  eye  except  a 
faint  dark  stain  around  the  edge  of  the  bullet  hole.  Some  differences  are  to 
be  noted  between  the  effects  producd  on  linen  by  the  Colt's  and  the  two  German 
pistols.  The  Colt  cartridges  were  loaded  with  a  green  granular  powder, 
probably  Walsrode.  This  powder  produced  a  faint  speckled  discoloration 
which,  when  examined  closely,  was  found  to  consist  of  a  moderate  number 
of  minute  black  grains,  adherent  to  but  not  deeply  embedded  among  the  fibers 
of  the  flax.  No  scorching  effect  could  be  detected.  Under  a  microscope  these 
grains  resembled  the  fused  masses  of  slag  from  a  smelting  furnace.  The 
Mauser  and  Luger  pistols  were  loaded  with  a  powder  which  consisted  of  thin 
squares  of  a  dark  grayish-black  color,  evidently  cut  from  a  sheet  of  the  mate- 


GUNSHOT   worxn.s 


39 


rial  from  which  the  powder  la  made.  I  have  been  unable  to  learn  the  name 
of  thia  powder,  but  ii  closely  resembles  the  powder  known  n<  Ballistite  in 
appearance,  although  the  squares  are  smaller.  These  powders  produced  a  fainl 
grayish  Bmudge  upon  the  linen  cloth  ;ii  a  distance  «>t'  three  Inches.  X"  distinct 
grains  ••mild  \n-  distinguished  with  the  naked  eye.  Under  the  microscope  the 
discoloration  was  seen  in  consist  of  uumerous  tine  black  angular  grains  em- 
bedded among  the  meshes  of  tin-  flax  fibers;  the  grains  were  aboul  equal  in 


Fig.  7.     Photograph  of  Two  Shots  to  Illustrate  the  Difference  in  the  Effects  i  pon    mu. 
Skin  of  Black  and  Smokeless  Powders  Respectively.      A  paper  label   N<>.  3  bas  been  pasted 

upon  tin-  skin.  I'pon  the  left  a  shol  lired  from  a  t hirt y-t wo  caliber  revolver  charged  with  black 
powder,  bullet  of  soft  lead  (shot  No.  7  as  described  in  the  text).  The  tattoo  marks  and  the 
staining  of  the  edges  of  the  wound  of  entrance  with  lead  are  plainly  visible.  Distance  of  muzzle 
from  skin  one  foot.  Upon  the  ritdit  a  shot  from  a  pistol  loaded  with  smokeless  powder  at  the  same 
distance  (Mauser).     No  powder  marks  are  visible  upon  the  skin. 


diameter  to  a  single  fiber  of  flax,  and  their  distribution  was  unite  different 
fn>ni  that  note. I  with  Walsrode  powder;  the  grains  were  also  much  smaller 
and  more  numerous. 

'Idic  changes  produced  in  linen  by  black  powder  were  quite  different.  At 
a  distance  of  three  inches  the  cloth  was  set  on  tire  around  the  margin  oi  the 
bullet  hole.  The  cloth  was  scorched  and  discolored  over  an  area  more  than 
three  inches  in  diameter,  and  numerous  powder-grain  mark-  were  scattered 
Over  the  scorched   area.      Under  the  microscope   these   marks   were   found   t"   he 


40 


WOUXDS 


due  to  the  presence  of  a  large  amount  of  brownish-black  granular  material 
plastered  on  the  surface  of  the  flax  bundles.  The  scorching  of  separate  bundles 
of  fibers  was  also  quite  evident. 

When  fired  at  paper  the  same  differences  were  to  be  noted  between  black 
and  smokeless  powders.     The  black  powder  caused  scorching  of  the  paper  at 


Fig.  8. — Photograph  of  Gunshot  Wound  of  the  Temporal  Region,  Suicidal,  what  is  Known  as 
a  Contact  Shot,  Produced  by  a  Thirty-eight  Caliber  Revolver  Loaded  with  Black  Powder. 
The  laceration  of  the  soft  parts  and  the  blackening  of  the  wound  edges  produced  by  the  black 
powder  can  be  seen.  The  wound  is  behind  the  eye  and  near  the  tip  of  the  middle  finger  of  the 
individual  who  is  raising  the  eyelid.  An  ether  cone  is  over  the  patient's  face.  Before  shooting 
himself  in  the  head,  the  patient  had  shot  himself  in  the  abdomen,  producing  numerous  perfora- 
tions of  the  intestine.  Since  there  were  no  cerebral  symptoms  at  the  time,  I  opened  his  abdomen 
and  closed  the  perforations  by  suture.  At  the  end  of  forty-eight  hours,  however,  he  became 
comatose  and  died  of  extensive  laceration  of  the  frontal  lobes  of  the  brain  and  intracranial  hemor- 
rhage.     (Author's  collection.) 

very  short  distances  (three  inches),  together  with  numerous  marks  of  powder 
grains  driven  into  the  paper.  At  the  distance  of  one  foot  the  scorching  was 
absent,  but  the  powder  grains  were  still  very  numerous  and  black.     The  smoke- 


GUNSHOT    WOUNDS  II 

less  powders  tired  ;ii  three  inches  caused  Blight  smudging  of  the  paper,  and 
numerous  little  indentations  of  the  surface  of  a  gray  color.  The  Mauser  car 
tridges  caused  more  discoloration  of  the  paper  and  fewer  indentations  than 
the  ('<>lf.  At  a  distance  of  one  fool  the  Mauser  produced  scarcely  any  percep- 
tible mark,  and  the  Coll  produced  a  few  slight  indentations  and  no  discol- 
orat  ions. 

Although  these  experiments  are  few  in  number  and  by  no  means  comp] 
a  few  conclusions  may,  1   think,  be  drawn  from  them. 

1.  Powder  marks  upon  the  skin  and  clothing  produced  by  smokeless  powder 
arc  much  less  distinct  and  definite  than  those  caused  by  Mack  powder. 

2.  With  the  weapons  u^k<\  in  these  experiments,  such  marks  cease  to  be 
produced  when  the  distance  exceeds  one  foot  and  the  shut  i-  tired  at  the  naked 
skin. 

3.  At  a  distance  of  three  inches  or  less,  powder  marks  may  he  present,  but 
they  will  always  he  faint,  and  may  in  many  instances  be  wiped  away  from 
the  skin  with  a  wet  or  dry  cloth. 

4.  If  the  shut  lie  tired  at  a  part  of  the  body  covered  with  clothing,  no 
powder  marks  at  all  will  he  found  upon  the  skin.  The  clothing  will  never  he 
scorched  no  matter  how  near  the  weapon  is  held.  If  the  clothing  he  wool,  no 
mark  is  likely  to  he  detected  upon  it,  even  at  the  closest  range.  If  the  clothing 
be  of  linen,  a  faint  mark  may  be  found  upon  it  if  the  weapon  were  held  at  a 
distance  of  three  or  four  inches  or  less.  If  the  distance  much  exceeded  this. 
no  mark  would  he  produced.  The  evidence  furnished  by  a  microscopic  exam- 
ination of  the  pieces  of  linen  appears  to  me  to  he  quite  interesting.  It  i-  evi- 
dent that  by  this  means  it  might,  in  certain  instances,  he  possible  to  state  with 
some  positiveness  that  a  certain  kind  of  ammunition  had  or  had  not  been  \\<n\. 
Such  a  conclusion  might  be  of  the  greatest  importance  from  a  medico-legal 
standpoint. 

II.  Wounds  Produced  by  Rifles  and  Rifled  Pistols  Loaded  with  Black 
Powder  and  Soft-lead   Bullets 

These  are  different  in  several  particulars  from  those  caused  by  high-powered 
rifles  and  pistols  loaded  with  smokeless  powders  and  jacketed  bullets.  The 
velocity  of  the  missiles  is  much  lower  and  the  penetration  much  less,  hence 
a  larger  proportion  of  these  bullets  lodge.  The  bullets  are  soft,  and  are  usually 
deformed  or  even  broken  up  when  they  strike  hard  hone.  Hence,  greal  lacera- 
tion of  soft  parts  occurs,  and  at  moderate  ranges  the  injuries  to  the  hard  shafts 
<d'  long  bones,  to  the  cranium,  and  to  the  solid,  glandular,  and  hollow  organs 
of  the  abdomen  resemble  the  so-called  explosive  effects  of  the  high-powered 
military  rifle;  indeed,  they  may  he  even  much  more  destructive  in  the  case 
of  rifles  of  large  caliber  firing  a  heavy  bullet.  At  longer  ranges,  when  the 
velocity  is  much  reduced,  these  effects  diminish,  and  finally  disappear. 

Wounds  by  soft  lead  rifle  bullets  at  short  ami  medium  ranges  arc  charac- 


42  WOUNDS 

terized  by  a  wound  of  entrance  of  about  the  diameter  of  the  bullet  itself,  assum- 
ing that  the  shot  is  a  direct  one  and  does  not  strike  the  surface  of  the  body 
obliquely.  Whereas  the  track  of  the  bullet  through  the  tissues  is  usually  much 
contused  and  much  larger  in  diameter,  and  the  wound  of  exit  is  frequently 
ragged  and  of  a  size  which  varies  within  wide  limits,  depending  upon  how 
much  the  bullet  has  been  deformed  or  broken  up  by  striking  bone,  by  the 
velocity  of  the  bullet,  and  by  its  size  and  weight.  But  in  general  it  may  be 
said  that  the  wound  of  exit  will  be  considerably  larger  and  more  ragged  than 
the  wound  of  entrance.  At  very  long  ranges,  when  the  velocity  of  the  bullet 
has  been  much  reduced,  and  its  rotation  due  to  the  rifling  diminished,  the 
wounds  will  be  simpler  in  character  and  attended  by  far  less  destruction  of 
tissue.  In  the  thicker  portions  of  the  body  at  long  ranges,  the  bullet  will  lodge 
or  make  a  wound  of  exit  but  little  if  any  larger  than  the  wound  of  entrance. 
At  low  velocities,  such  bullets,  if  of  small  caliber,  may  even  fail  to  cause  frac- 
tures of  bones,  and  may  be  more  or  less  completely  flattened  against  the  harder 
portions  of  bones,  or  even  against  the  skull.  The  wounds  of  the  lungs  or  of 
the  brain,  or  of  the  hollow  organs  of  the  abdomen,  or  of  the  glandular  organs 
of  the  abdomen,  will  in  many  instances  be  simple  perforations,  without  much 
laceration  of  the  neighboring  tissues  (assuming  that  the  range  is  great  or  the 
initial  velocity  low). 

Wounds  of  blood-vessels  produced  by  soft-lead  bullets  fired  from  rifles  at 
short  or  medium  range  are  often  even  more  destructive  than  the  wounds  pro- 
duced by  the  small-calibered  high-powered  bullet.  They  are  also  more  frequent 
as  the  result  of  the  greater  size  of  the  missile,  and  vary  from  complete  or  par- 
tial severance  of  the  vessel  to  contusion  and  laceration  of  one  or  more  of  its 
coats,  sometimes  with  the  subsequent  production  of  aneurism.  Wounds  of  the 
nerves  produced  by  soft-lead  bullets  vary  much  in  the  same  way  as  do  wounds 
of  the  blood-vessels,  but  contusions  and  partial  lacerations  of  nerve  trunks  are 
more  common  than  with  the  small-calibered  bullets.  At  long  ranges  and  at  low 
velocities,  blood-vessels  and  nerves  may  often  be  pushed  aside  by  these  bullets 
and  escape  actual  division,  suffering  only  contusion  of  greater  or  less  severity. 

Wounds  produced  by  revolvers  and  pistols  of  small  and  moderate  caliber 
are  usually  of  a  less  complicated  character  than  are  wounds  produced  by  rifle 
bullets.  The  charge  of  powder  is  small  and  the  velocity  of  the  bullet  relatively 
low.  In  consequence  the  lateral  destructive  action  is  much  less  noticeable,  and 
with  the  smaller  calibers,  .22  and  .32,  lodgment  of  the  bullet  is  the  rule  rather 
than  the  exception  in  the  thicker  parts  of  the  body.  The  fractures  of  the  bones 
produced  are  generally  accompanied  by  less  comminution,  and  the  explosive 
action  noted  in  the  case  of  large  and  more  powerful  weapons  is  rarely  marked. 

From  the  size  and  shape  of  soft-lead  bullets,  portions  of  the  clothing  are 
much  more  commonly  carried  into  the  depths  of  the  wound  than  is  the  case 
with  the  small-calibered  weapons.  Owing  to  the  larger  size  of  soft-lead  bullets, 
and  especially  owing  to  the  greater  size  of  the  wounds  of  exit  produced  by 
soft-lead  rifle  bullets,  infection  of  the  wound  is  apt  to  occur.     But  even  in 


GUNSHOT    WOUNDS  43 

these  wounds  it  has  1 »« -< - 1 1  noted  in  recenl  years  thai  noninterference  with  the 
deeper  portions  of  the  wound  is  attended  by  greatly  improved  results  in  this 
respect.  Unless  tli«'  bullel  has  produced  some  injury  which  in  itself  demands 
operative  interference,  such  as  ;i  wound  of  one  of  the  hollow  abdominal  viscera, 
a  wound  "I"  ;i  blood-vessel  or  nerve,  <»r  an  extensively  comminuted  compound 
fracture,  the  more  nearly  it  can  be  treated  as  a  subcutaneous  injury,  <>r  rather 
the  more  nearly  it  can  be  made  to  resemble  a  subcutaneous  injury,  the  less 
likely  is  infection  to  take  place  and  the  better  the  prognosis. 

The  diagnosis  of  bullet  wounds  of  special  regions  and  of  special  organs 
will  lie  spoken  of  under  the  head  of  Regional  Surgery. 

TIT.  Wounds   Produced  p.y  Shotguns 

These  vary  greatly  in  severity.  The  variations  depend  first  upon  the  size 
of  the  shot  constituting  the  load,  and  second  upon  the  range  at  which  the  -hot 
is  tired.  Buckshot,  that  is  to  say  spherical  soft-lead  bullets,  varying  in  weighl 
from  eighl  to  twelve  t"  the  ounce,  tired  from  a  shotgun,  produce  wounds  not 
very  unlike  those  produced  by  small  rifle  or  revolver  bullets,  except  that, 
inasmuch  as  they  do  not  rotate  in  an  axis  parallel  with  the  line  of  flight,  there 
is  less  lateral  or  explosive  effect  at  all  ranges.  The  ordinary  loud  of  a  shotgun 
for  such  missiles  varies  in  number  from  eight  to  twelve.  At  short  ranges,  as 
will  he  noted  under  the  head  of  wounds  produced  by  fine  shot,  such  a  load 
striking  the  body  fairly  produces  the  most  terrible  injuries.  If  they  strike  the 
head  or  thorax  or  the  abdomen,  the  amount  of  destruction  of  tissue  is  very 
great,  attended  by  severe  shock,  and  such  injuries  are  commonly  rapidly  or 
immediately  fatal.  If,  on  the  other  hand,  the  range  is  considerable,  say  one 
hundred  yards  or  more,  the  character  of  the  wound  resembles  quite  closely  that 
produced  by  a  small  revolver  bullet  traveling  at  similar  velocity,  and  such 
bullets  will  often  lodge  in  the  thicker  portions  of  the  body.  Wounds  produced 
by  small  shot,  such  as  are  used  in  tiring  at  upland  game — No.  8,  for  example, 
containing  400-500  pellets  in  the  charge1 — are  of  all  degrees  of  severity,  de- 
pending upon  the  range.  The  ordinary  load  for  a  shotgun  of  1 1'  gauge  is  one 
and  one  eighth  ounce  of  such  shot.  For  a  shotgun  of  10  gauge  it  is  commonly 
one  and  one  quarter  ounce.  At  ranges  less  than  and  up  to  forty  feet,  such  a 
load  tired  from  an  ordinary  shotgun,  such  as  is  used  for  sporting  purposes,  has 
the  effect  when  it  strikes  the  body  fairly,  in  part  at  least,  of  a  single  missile, 
and  the  destruction  of  the  tissues  is  great. 

Tn  order  to  determine  the  effects  of  charges  of  small  shot  tired  at  the  human 
body,  T  made  a  certain  number  of  experiments  upon  the  cadaver  with  various 
sizes  of  shot  and  with  various  loads  of  smokeless  powder.  The  shotgun  used 
was  a  12-gauge  Parker  gun — what  is  known  as  a  close-shooting  gun.  The 
subjed  was  suspended  by  the  head,  in  the  ereel  posture,  and  all  the  shots  but 
one  were  fired  from  in  front.  The  thickness  of  the  body  through  the  abdomen 
from  before  backward  was  eight  and  one  half  inches. 


44 


WOUNDS 


Shot  I. — Load,  thirty-seven  grains  of  Dupont's  smokeless  powder,  said  to  be 
equivalent  to  three  drachms  of  ordinary  black  powder;  one  and  one  eighth  ounce 
of  Xo.  4  shot,  The  gun  was  fired  at  the  umbilical  region,  at  a  distance  of  eighteen 
feet.  The  spread  of  the  shot  was  three  and  one  half  inches.  In  the  center  of  the 
wound  there  was  a  ragged  hole  torn  through  the  abdominal  wall  extending  into 
the  peritoneal  cavity.  There  was  a  soft  bulging  tumor  produced  in  the  back  nearly 
in  the  middle  line,  and  about  the  size  of  the  closed  fist,  and  individual  shot  could 
be  felt  in  and  beneath  the  skin  of  the  back  over  this  area.  The  shot  did  not 
emerge  through  the  skin  of  the  back. 

Shot  II. — Same  load;  distance,  thirty-five  feet;  shot  was  fired  at  epigastrium. 
Spread  of  shot  was  over  an  area  seven  inches  in  diameter.     The  shot  wounds  were 


Fig.  9. — To  Illustrate  the  Effects  upon  the  Body  of  a  Shotgun  Loaded  with  Birdshot  and 
Fired  at  Close  Range.  The  label  No.  4  has  been  pasted  upon  the  abdominal  wall.  In  the  center, 
just  to  the  right  of  the  subject's  navel,  shot  No.  1  as  described  in  the  text.  Distance  eighteen 
feet.  To  the  right  and  to  the  left  are  seen  the  wounds  produced  at  the  same  range  with  finer  shot, 
as  described  in  the  text. 


discrete,  except  near  the  center,  where  was  a  ragged  hole  one  inch  in  diameter 
through  the  abdominal  wall.  In  this  hole  there  was  embedded  a  felt  powder  wad. 
The  shot  did  not  emerge  from  the  back. 

Shot  III. — Cartridge  loaded  with  twenty-four  grains  of  Ballistite  powder,  said 
to  be  equivalent  to  two  and  three  fourth  drachms  of  black  powder;  one  and  one 
eighth  ounce  of  Xo.  9  shot;  distance,  eighteen  feet.     Shot  was  fired  at  the  lower 


GUNSHOT    WOUNDS 


45 


pari  of  the  abdominal   wall,  to  the  lefl  of  the  median   line.     Spread  of  the  shot 
w;is  six  inches  in  diameter.    There  was  ;i  ragged  hole  through  the  abdominal  wall 
one  and  one  half  inch  in  diameter,  and  a  sofl  bulging  tumor  just  above  the 
of  i  he  ilium  in  I  he  back. 

Shot  [V.— Load,  thirty-nine  grains  of  new  Schultze  powder,  Baid  to  be  equiva- 
lent to  three  drachms  of  black  powder;  one  and  one  eighth  ounce  of  No.  ~>  \  shot 


Pig.  10.  Underneath  the  Paper  Label  No.  5  is  a  Photograph  of  Shot  X<>.  2  as  Debcribi  i>  in 
tiik  Text.  Range,  thirty-five  feet.  To  the  left  and  above  is  shot  No.  1  as  described  in  the  text 
Range,  eighteen  feet. 

— What  is  known  as  a  pigeon  load.  The  shot  was  fired  a(  the  thoracic  wall  uear 
ilic  nipple,  a!  a  distance  of  eighteen  feet.  There  was  a  ragged  hole  one  and  one 
half  inch  in  diameter,  in  (lie  thoracic  wall.  A  good  many  of  the  shot  passed  through 
the  thorax,  emerged  from  the  hack,  and  embedded  themselves  in  the  slaves  of  a 
barre]  placed  behind  the  body. 

Shot  Y. — 'This  shot  was  fired  through  the  thorax  from  behind  at  a  distance  of 
*i\    iVct.     There   were  no   powder  marks  141011   the  skin    (smokeless  powder).     The 


46  WOUNDS 

wound  of  entrance  was  but  little  larger  than  the  caliber  of  the  gun.  The  wound 
of  exit  in  the  back  was  a  slit  three  inches  in  length.  Nearly  the  entire  charge 
passed  through  the  thorax  and  embedded  itself  in  the  barrel  behind,  including  a 
felt  powder  wad  which  was  found  wedged  between  two  barrel  hoops.  Fragments 
of  lung  and  heart  tissue  were  plastered  on  the  barrel  and  the  wall  of  the  room 
was  extensively  splattered  with  the  same  material. 

At  greater  ranges  the  wounds  produced  by  fine  shot  would  be  discrete,  and 
the  penetration  and  destruction  of  tissue  would  vary  with  the  range,  with  the 
powder  charge,  with  the  size  of  the  shot,  with  the  thickness  of  the  clothing 
if  a  clothed  part  of  the  body  were  struck,  and  also  as  the  shot  was  a  direct  one 
or  a  ricochet.  Generally  speaking,  at  considerable  ranges — a  hundred  feet  or 
more — wounds  produced  by  fine  bird  shot  will  be  quite  discrete  and  attended 
by  very  little  serious  injury,  unless  it  happens  that  one  of  the  shot  enters  the 
eye  or  happens  to  penetrate  a  thin  portion  of  the  skull,  as  noted  under  Injuries 
of  the  Head.  Such  wounds,  if  let  alone,  will  rarely  be  attended  by  suppura- 
tion, and  the  pellets  will  generally  remain  embedded  in  the  tissues  without 
producing  any  serious  disturbance.  Search  for  them  by  operative  measures 
is  generally  ill  advised ;  if  they  cause  trouble  by  pressure  upon  nerves,  or  if 
embedded  in  the  eyeball  or  other  delicate  organ,  they  may  be  located  by  means 
of  the  X-rays  by  methods  to  be  described. 


IV.  Wounds  Produced  by  Artillery 

These  are  of  several  different  types.  Wounds  produced  by  large  solid 
projectiles  and  by  large  fragments  of  exploding  shells  may  be,  and  often  are, 
immediately  fatal.  Decapitation,  disembowelment,  complete  amputation  of  one 
or  more  extremities,  and  even  the  cutting  of  the  human  body  in  two,  are 
common  enough  in  time  of  war.  In  the  days  when  the  old-fashioned  round 
mortar  shells  were  used,  the  shells  commonly  burst  into  large  fragments,  and 
the  wounds  produced  by  such  fragments  were  contused  and  lacerated  wounds, 
often  attended  by  immediate  death,  or  by  great  laceration  of  tissue  and  severe 
shock.  It  frequently  happened  that,  unless  such  wounds  involved  one  of  the 
extremities  merely,  the  wounded  died  upon  the  field  and  did  not  come  under 
surgical  treatment.  At  the  present  time  all  the  artillery  used  in  warfare  is 
rifled.     The  missiles  are  of  three  kinds: 

First,  there  are  the  armor-piercing,  or  ordinary,  shells,  made  of  steel  and 
containing  a  charge  of  powder,  or  sometimes  of  a  high  explosive,  and  intended 
to  burst  either  at  a  given  range  or  by  impact.  Such  shells  are  fired  at  forti- 
fications or  at  vessels  of  war,  more  or  less  completely  protected  by  steel  armor. 

Second,  there  are  shrapnel :  shells  of  a  similar  shape,  but  thinner,  contain- 
ing a  bursting  charge  of  powder  and  a  large  number  of  round  leaden  bullets 
and  discs  of  iron.  Such  shells  are  fired  at  bodies  of  troops  at  ranges  varying 
from  1,000  to  6,000  or  8,000  yards.     They  are  sometimes  burst  by  a  time 


HEMORRHAGE  47 

fuse  and  Bometimee  by  impact  Shrapnel  is  effective  up  to  from  L,000  to 
4,000  meters;  caliber,  three  inches.  Sheila  fired  from  breech-loading  rifled 
Biege  guns  arc  effective  at  8,000  and  1.0,000  meters. 

The  projectiles  consisting  of  the  jagged  fragments  of  exploded  shell  and  of 
the  contained  bullets  derive  their  momentum  partly  from  the  original  momen- 
tum of  the  projectile,  cover  a  considerable  area,  conical  in  shape,  and  may 
be  terribly  destructive  to  groups  or  masses  of  troops  at  greal  ranges.  The 
wounds  produced  are  partly  those  of  the  jagged  fragments  of  the  shell  itself 
and  partly  those  of  the  contained  hard-lead  bullets.  The  fragments  of  Bhell 
produce  contused  and  lacerated  wounds  of  all  degrees  of  severity  :  man\  of  them 
are  immediately  or  speedily  fatal  from  laceration  and  destruction  of  important 
organs. 

The  Indict  wounds  do  no1  vary  much  diagnostic-ally  from  those  produced 
by  the  small-calibered  rifle  bullets;  hut  from  the  great  ranges  at  which  they 
are  commonly  fired  they  will  often  lodge  in  the  thicker  port  ions  of  the  body 
rather  than  perforate.  The  differential  diagnosis  between  such  wound-  and 
those  produced  by  the  military  rifle  can  often  be  made  by  means  of  a  radio- 
graph, since  the  bullets  are  spherical  and  not  cylindrical. 

Third,  there  arc  the  canister,  consisting  of  a  thin  casing  of  metal  contain- 
ing a  large  number  of  leaden  bullets,  hardened  and  of  considerable  size;  they 
are  supposed  to  bursl  soon  after  leaving  the  muzzle  of  the  cannon,  and  produce 
the  effects  of  a  shotgun,  but  on  a  greatly  magnified  scale.  At  short  ranges  the 
results  are  very  destructive,  and  such  wounds  are  often  immediately  fatal. 

It  would  he  supposed  from  the  far  greater  efficiency  of  modern  firearms 
that  the  number  of  fatalities  in  battle  would  he  greatly  increased,  hut  it  i-  to 
he  remembered  that  troops  at  the  present  time  seldom  approach  one  another 
much  nearer  than  500  or  GOO  yards  in  the  daytime,  and  experience  has  shown 
that  the  percentage  of  mortality  has  rather  been  diminished  than  increased. 
Troops  no  longer  advance  against  the  enemy  in  compact  masses,  but  in  scat- 
tered formation,  and  the  soldiers  are  trained  to  take  advantage  of  every  kind 
of  protection  afforded  by  rocks,  trees,  and  inequalities  of  the  ground.  It  is 
true  that  the  smaller  size  and  weight  of  modern  small-arm  ammunition  permits 
the  soldier  to  carry  from  100  to  200  rounds,  but  the  number  of  hit-  is  greatly 
diminished  by  the  great  ranges  at  which  the  shots  musl  be  tired.  Imperfectly 
armed  and  partly  civilized  or  savage  peoples  suffer  a  very  high  mortality  when 
their  ignorance  or  temerity  leads  them  to  charge  upon  trained  troops  armed 
villi  modern  military  rifles,  but  such  conditions  are  exceptional. 

HEMORRHAGE 

Bleeding  from  Arteries. —  Arterial  blood,  under  normal  conditions,  is  bright 
red  in  color,  and  escapes  in  jets  projected  sometimes  to  a  distance  of  several 
feet.  If  the  wound  be  deep,  the  appearance  of  a  jet  of  blood  may  be  absent 
When  a  large  artery  is  divided  in  a  wound,  the  blood  escapes  with  a  hissing 


48  WOUNDS 

sound  similar  to  that  caused  by  water  escaping  from  a  rubber  hose  or  pipe. 
The  division  of  an  artery  as  large  as  the  femoral  or  the  brachial  is  fatal  in  a 
few  moments  unless  checked  artificially.  The  diagnosis  of  arterial  bleeding 
may  usually  be  made  very  readily  by  these  signs.  In  the  condition  of  syncope, 
when  the  heart  acts  feebly,  the  projection  of  the  blood  in  jets  may  be  absent; 
and  in  asphyxia,  such  as  sometimes  accompanies  deep  surgical  anesthesia  from 
chloroform  or  ether,  the  blood  may  be  dark  in  color,  even  almost  black.  Pres- 
sure upon  the  trunk  of  the  vessel  between  the  bleeding  point  and  the  heart 
causes  cessation  of  the  hemorrhage,  or  at  least  marked  diminution.  If,  how- 
ever, the  vessel  be  in  a  region  like  the  face,  where  a  rich  anastomosis  exists, 
bleeding  may  occur  from  both  ends  of  a  divided  vessel,  but  that  from  the  distal 
end  will  usually  be  continuous,  and  not  in  jets.  The  same  condition  obtains 
if  the  distal  portion  of  the  vessel  in  an  extremity  gives  off  a  large  arterial 
branch  near  the  place  of  wounding.  The  anatomical  situation  of  the  wound 
is  usually  a  good  guide  to  the  vessel  wounded.  In  certain  regions — the  abdo- 
men, the  neck,  and  some  other  situations — the  large  number  of  arterial  trunks 
may  render  this  guide  unreliable.  Arterial  bleeding  in  special  regions — the 
abdomen,  the  interior  of  the  skull,  etc. — gives  rise  to  special  symptoms,  to  be 
spoken  of  under  the  head  of  Regional  Surgery. 

Bleeding  from  Veins. — Bleeding  from  veins  is  to  be  distinguished  by  the 
darker  color  of  the  blood,  by  its  continuous  flow — not  in  jets  but  in  a  steady 
stream — and  by  seeing  the  wounded  or  divided  vein,  if  superficial.  In  wounds 
of  veins  of  the  extremities  the  bleeding  may  be  stopped  by  slight  pressure  over 
the  bleeding  point.  Pressure  upon  the  vessel  between  the  wound  and  the  heart 
may  increase  the  flow  of  blood.  Pressure  upon  the  vessel  upon  the  distal  side 
of  the  wound  stops  the  bleeding,  unless  a  large  venous  branch  enters  the  prox- 
imal portion  of  the  vein  distal  to  any  valve.  Ordinarily,  elevation  of  the  limb 
and  light  pressure  over  the  divided  vein  are  sufficient  to  stop  venous  bleeding. 
In  certain  regions,  notably  in  the  neck  and  in  the  abdomen,  valves  in  the  veins 
are  few  or  absent,  and  here  venous  bleeding  may  occur  from  both  ends  of  the 
divided  vessel,  and  may  be  severe,  dangerous,  or  fatal.  In  the  disease,  varicose 
veins  of  the  leg,  the  valves  may  be,  and  often  are,  incompetent,  and  bleeding 
may  occur  from  both  ends  of  the  vessels.  Under  improper  treatment  main- 
tenance of  the  erect  position,  pressure  upon  the  proximal  side  of  the  venous 
trunk,  etc.,  such  bleeding  may  be  dangerous,  and  even  fatal. 

Aspiration  of  Air  into  the  Veins. — In  the  veins  at  the  root  of  the  neck 
aspiration  by  the  thoracic  respiratory  movements  may  result  in  the  entrance 
of  air  into  the  veins,  with  alarming  or  fatal  symptoms.  The  veins  of  this 
region  are  large  and  rather  firmly  adherent  to  the  surrounding  tissues,  and 
do  not  readily  collapse  when  opened.  The  accident  is  a  rare  one.  The  signs 
are  a  hissing,  gurgling  sound  heard  in  the  wound,  and  sudden  heart  failure, 
with  some  symptoms  of  asphyxia,  and  death.  Air  enters  the  right  side  of  the 
heart,  and  the  contractions  of  the  ventricle  are  unable  to  force  the  foamy  mix- 
ture of  air  and  blood  through  the  lungs.     Often  the  first  symptoms  noticed  are 


HEMORRHAGE  \<j 

sikIiIih  heart  failure  and  death.     When  only  m  Little  air  enters  a  vein,  n<>  symp- 
hiin-  ni;i\  be  Qoticedj  or  the  patient  may  Buffer  from  moderate  and  sudden  fall 
of  blood  pressure  and  rapid  ami  feeble  heart  action,  which  are  gradually  r» 
crcd  from. 

Parenchymatous  and  Capillary  Bleeding. — Bleeding  from  the  parenchyma  of 

organs  is  a  mixture  of  arterial  and  venous  hemorrhage.     The  1>I I  is  of  rather 

brighl  color,  wells  up  from  the  entire  raw  surface,  sometimes  very  rapidly,  and 
such  bleeding  may  be  dangerous  or  even  fatal.  Some  authors  do  doI  differ- 
entiate this  variety  of  bleeding  from  capillary  hemorrhage,  in  which  again  the 
blood  is  of  father  brighl  color,  and  oozes  from  the  entire  raw  surface.  Danger 
mis  bleeding  from  small  vessels  is  common,  especially  under  three  pathological 
conditions:  profound  and  prolonged  jaundice,  hemophilia,  and  splenic  leuke- 
mia. Severe  and  fatal  bleeding  sometimes  follows  operations  upon  persons  who 
have  been  deeply  jaundiced  for  some  time.  The  bleeding  may  occur  at  the 
time  of  the  operation  from  all  the  tissues,  and  be  continuous  until  death,  or  it 
may  begin  several  days  after  the  operation  in  a  clean  wound  from  some  small 
vessel  or  vessels  in  the  subcutaneous  tissues,  or  from  the  peritoneum,  or  from 
both.  This  bleeding  is  often  insidious,  and  is  not  noticed  until  the  signs  of 
intraperitoneal  hemorrhage,  or  distention  of  the  external  wound,  and  staining 
of  the  dressings,  and  the  weakened  condition  of  the  patient  attract  the  sur- 
geon's attention.  It  seems  to  depend  upon  a  diminished  power  of  coaiiulahility 
of  the  blood,  and  is  of  bad  prognostic  significance. 

Hemophilia. —  Hemophilia  is  a  disease  transmitted  through  the  females  of 
a  family  to  the  males,  among  whom  it  generally  occurs.  The  pathology  of  the 
disease  is  obscure.  Many  explanations  of  the  condition  have  been  offered; 
none  are  entirely  satisfactory.  The  diagnosis  is  not  difficult.  There  is  usually 
from  infancy  or  early  boyhood  a  tendency  to  profuse,  persistent,  and  recurrent 
bleeding  from  the  skin,  mucous  membranes,  and  other  tissues.  Slight  injuries, 
such  as  a  needle  prick,  a  Mow  upon  the  nose,  a  trifling  wound,  or  the  extraction 
of  a  tooth,  are  followed  by  continuous  bleeding,  which  may  resi<r  all  ordinary 
means  to  check  it.  The  bleeding  may  cease,  only  to  recur  again  when  pressure 
is  removed  or  a  scab  or  (dot  is  separated.  This  persistent  bleeding  from  slight 
injuries  suffices  to  establish  the  diagnosis.  Ordinary  surgical  operations  upon 
such  individuals  are  dangerous,  and  even  fatal. 

Symptoms. — The  signs  and  symptoms  of  excessive  bleeding  are  to  he  ob- 
served after  accidents,  after  severe  surgical  operations  involving  much  loss  of 
blood,  after  parturition,  and  after  operations  undertaken  tor  the  purpose  of 
checking  hemorrhage  following  accident  or  disease.  These  signs  and  symp- 
toms  are  sometimes  observed  alone,  hut  more  commonly  they  are  combined  with 
the  symptoms  of  shock,  and  nol  infrequently  with  the  depressing  effects 
general  anesthetics,  notably  chloroform,  and  sometimes  ether.      The  signs  ami 

symptoms  following  serious  los^  of  blood  are  as  follows:  The  face,  the  mucous 
membranes,  and  the  general  cutaneous  surface  are  pale;  the  extremities  are 
cold;  the  pulse  becomes  rapid,  feeble,  and  compressible;  the  patient  suffers  from 


50  WOUNDS 

a  feeling  of  extreme  weakness ;  syncope  may  follow  if  the  patient  assumes  the 
erect  posture,  or  may  occur  spontaneously  if  the  loss  of  blood  continues ;  there 
are  ringing  in  the  ears,  giddiness,  often  spots  before  the  eyes,  thirst,  restless- 
ness, and  sometimes  extreme  irritability ;  the  patient  may  toss  and  twist  himself 
about  incessantly;  the  features  are  drawn,  and  the  expression  of  the  face  is 
anxious ;  there  may  be  nausea  and  vomiting ;  there  is  air  hunger  and  gasping 
for  breath,  due  to  anemia  of  the  respiratory  center  of  the  medulla.  Rapid, 
fatal  bleeding  is  accompanied  by  intense  dyspnea,  by  general  convulsions,  by 
unconsciousness,  dilated  pupils,  and  the  involuntary  evacuation  of  the  contents 
of  the  bladder  and  rectum.  A  sign  common  to  shock  and  severe  bleeding  is 
a  marked  fall  of  arterial  blood-pressure.  If  the  bleeding  is  not  very  great  and 
is  stopped,  the  arterial  pressure  soon  rises  to  normal  or  nearly  to  normal. 

The  Eiva  Rocci  Apparatus. — A  special  apparatus  has  been  devised  for  the 
determination  of  the  arterial  blood-pressure  during  the  performance  of  surgical 
operations.  It  consists  of  a  hollow  band  or  tube  of  rubber,  which  is  made  to 
surround  the  upper  arm.  The  tube  communicates  on  the  one  hand  with  a 
mercurial  manometer,  and  on  the  other  with  a  rubber  hand  bulb,  by  means  of 
which  the  tube  surrounding  the  arm  may  be  inflated  with  air,  and  thus  the 
tube  may  be  made  to  constrict  the  arm  more  and  more  forcibly.  A  degree  of 
constriction  is  finally  reached  such  that  the  caliber  of  the  brachial  artery  is 
obliterated,  and  with  it  the  radial  pulse.  The  height  of  the  mercury  in  the 
manometer  records  the  pressure  necessary  to  stop  the  arterial  blood  current. 
Thus  the  amount  of  pressure  over  the  brachial  artery  necessary  to  obliterate  the 
radial  pulse  may  be  tested  from  time  to  time  during  the  performance  of  an 
operation,  and  indications  may  be  obtained  in  this  manner  for  stimulation,  for 
infusion  of  salt  solution,  or  other  measures  intended  to  make  up  for  the  loss 
of  blood. 

Blood  Changes  after  Hemorrhage. — In  addition  to  diminution  of  the  blood- 
pressure,  important  changes  occur  in  the  composition  of  the  blood  as  the  result 
of  severe  hemorrhage.  There  is  a  rapid  transfusion  of  the  tissue  fluids  into 
the  blood-vessels,  and  also  a  considerable  flow  of  lymph. 

The  fluid  which  replaces  the  lost  blood  is  necessarily  of  different  composition 
from  the  plasma,  and  its  addition  to  the  circulation  markedly  affects  the  composi- 
tion of  the  blood  after  hemorrhage.  The  blood  when  restored  to  its  normal  volume 
is  found  to  be  low  in  albumins,  rich  in  salts,  and  poor  in  red  cells.  If  the  hemor- 
rhage is  rapid  the  alkalinity  of  the  blood  is  diminished,  while  its  coagulability  is 
much  increased.  The  hydremia  affects  principally  the  plasma,  but  Herz  found  the 
volume  of  the  real  red  cells  greatly  increased  after  severe  hemorrhage,  indicating 
that  they  had  absorbed  much  water. 

In  man,  a  distinct  interval  is  required  before  the  fluids  have  replaced  the  lost 
blood,  and,  according  to  Limbeck,  thirt)r-five  to  forty  minutes  may  elapse  before 
a  distinct  reduction  of  red  cells  is  observed  after  moderately  severe  hemorrhage. 
The  changes  in  the  number  of  red  cells  following  hemorrhages  are  somewhat  irregu- 
lar, but  a  number  of  observers  have  shown  that  in  man  a  single  large  hemorrhage 


HEMOKRHAGE  51 

reduces  the  red  cells  in  proportion  considerably  less  than  the  effect  upon  the  vol- 
ume of  the  blood,  beginning  aboul  one  hair  bour  after  the  operation,  reaching  a 

max i in i dBfecl  in  three  to  four  days,  and  followed  by  a  restoration  to  the  oormal 

number  in  nineteen  to  thirty-four  days. 

Healthy  men  recover  rapidly  from  moderately  severe  hemorrhages.  Small  and 
repeated  hemorrhages,  on  the  other  band,  have  led  to  -nun-  of  the  mosl  Bevere 
forms  of  anemia,  the  prevailing  feature  heing  the  diminished  quantity  of  hemo- 
globin. Very  extensive  observations  have  been  made  on  the  condition  of  the  blood 
after  hemorrhages  by  Bierfreund,  in  the  clinic  of  Prof.  v.  Mikulicz.  He  found 
that  the  regeneration  of  the  blood  is  must  rapid  in  male  subjects  between  the 
of  twenty  and  forty  years.  A  Loss  amounting  to  five  per  ceni  of  hemoglobin  was 
found  to  lengthen  the  period  of  regeneration  two  to  eight  days.  The  minimum 
peicen tap'  of  hemoglobin  was  reached,  after  a  loss  ,,f  ten  to  fifteen  per  cent,  in 
three  days  and  a  half:  after  twenty-six  per  cent,  in  9.6  days;  in  women  usually 
one  day  later  than  with  men.  (Adapted  from  Ewing,  "  Clinical  Pathology  of  the 
Blood.") 

Certain  Effects  of  Severe  Hemorrhage. — It  is  generally  accepted  that  if  the 
amount  of  hemoglobin  is  less  than  thirty  per  cent  it  is  unwise  to  perform  any 
serious  surgical  operation.  There  are,  however,  exceptions  to  this  rule,  and 
patients  whose  hemoglobin  was  reduced  to  twenty  per  cent  have  survived  serious 
operations.  The  effects  of  the  loss  of  blood  vary  much  in  different  individuals. 
If  the  blood  is  lost  slowly  and  gradually,  the  effects  arc  less  dangerous  than 
though  one  single  large  hemorrhage  has  occurred  of  equal  amount.  Generally 
speaking,  a  loss  of  one  quarter  of  the  total  volume  of  blood  constitutes  a  very 
serious  hemorrhage,  but  instances  are  recorded  in  which  half  the  percentage 
of  red  cells  has  been  lost,  and  yet  recovery  has  taken  place.  In  dogs  it  bas 
he.n  found  that  a  loss  of  blood  equivalent  to  five  per  cent  of  the  body  weight  is 
always  fatal. 

Methods  of  Estimating  the  Quantity  of  Hemoglobin  in  the  Blood. — The  per- 
centage of  the  loss  of  hemoglobin  may  be  determined  by  means  of  the  instru- 
ment known  as  the  hemoglobinometer,  in  which  the  color  of  the  blood,  diluted 
to  a  certain  definite  proportion,  is  compared  with  the  color  of  a  wedge-shaped 
piece  of  red  glass.  Miescher's  modification  of  FleischPs  hemoglobinometer  is 
the  instrument  commonly  used,  and  one  which  gives  fairly  accurate  result-. 
The  blood  is  drawn  from  a  small  wound  into  a  graduated  pipette,  and  mixed 
with  200  or  300  or  400  parts  of  water,  and  the  color  of  this  mixture,  placed 
in  a  cell  of  a  certain  depth,  is  compared  with  the  color  of  a  wedge  ^i  red  glass, 
both  being  viewed  against  a  white  background.  A  fairly  satisfactory  method 
of  estimating  the  hemoglobin  is  by  comparing  the  color  of  a  piece  of  white 
bibulous  paper  dipped  in  the  blood  to  be  tested  with  a  standardized  series  of 
colored  slips  of  paper  mounted  on  a  card.  bach  slip  represents  accurately  the 
color  of  a  blood  solution  containing  a  definite  percentage  of  hemoglobin.     The 

test  IS  sufficiently  accurate  for  practical   purposes.      (The  Tallqvist   Scale.) 

The  comparison  must  be  made  by  daylight.     The  moat  satisfactory  instru- 


52 


WOUNDS 


ment  for  estimating  the  amount  of  hemoglobin  is  Dare's  Hemoglobinometer, 
or  the  Fleisehl-Miescher.  The  undiluted  blood  is  drawn  by  capillary  attrac- 
tion between  two  glass  plates,  which  form  a  chamber  of  definite  thickness. 


Fig.  11. — Fleischl-Miescher  Hemoglobinometer.     (Wood.) 

The  color  is  then  compared  with  the  color  plate  of  the  instrument.  When  the 
colors  are  matched  the  reading  of  a  suitable  scale  indicates  the  percentage  of 
hemoglobin  in  the  blood. 


Fig.   12. — Hematocytometer.     (Wood.) 

Estimation  of  the  Red  Cells. — The  estimation  of  the  actual  number  of  red 
cells  contained  in  a  specimen  of  blood  is  a  somewhat  complicated  procedure. 
A  description  of  it,  and  of  the  method  of  its  use,  is  quoted  from  Ewing,  "  Clin- 
ical Pathology  of  the  Blood,"  p.  35  et  seq. 


HEMORRHAGE 


53 


The  Hi.mm'k  rTOMETEB.-  The  Lnstrumenl  qoh  in  use  for  counting  blood  cells 
is  thai  of  Thoma,  who  combined  and  improved  several  features  of  instruments  pre- 
viously devised  by  Hayera,  Gowers,  and  Malassez.  This  apparatus  consists  of  ;i 
mixing  pipette  and  ;i  counting-chamber. 

(a)  The  pipette  is  .1  capillary  tube  graduated  in  ten  equal  divisions,  sur- 
mounted by  a  bulb  of  exactly  one  hundred  times  the  capacity  of  the  tube,  and  to 
which  is  attached  a  rubber  tube  and  mouthpiece  (  l"iur.  12).  When  the  tube  is 
filled  with  blood  ap  to  the  mark  I,  and  this  is  mixed  with  a  diluting  fluid  sucked 
up  in  the  mark  101,  a  Bpecimeu  of  blood  is  obtained  in  the  dilution  of  1:100. 
By  lillinur  only  one  half  the  tube  with  blood,  up  to  tin*  mark  0.5,  the  subsequent 
dilution  is  in  the  proportion  of  1:200.  The  bulb  contain-  a  glass  ball  to  facilitate 
the  mixing  of  the  blood. 

(A)  The  counting-chamber  is  constructed  so  as  to  secure  a  layer  of  diluted 
hlood    ,1ij    nun.    in    depth   over   a   certain    pqnare   ana.      <>n   a    thick  glass   Blide   is 


BlBBIB  Nil  IIII  III BIBIBIB 

BIBIBIB  IIII  IIII  IIII  IIIIBIBIBIB 
BIBIBIB  IIII  IIII  IIII  IIIIBIBIBIB 

BIBIBIB  IIII  IIII  IIII  UIIBIBIBIB 

iiiiiii  iiii  iiii  iiii  iiiiiiiiiii 

BIBIBIB  Nil  IIII  IIII  IIIIBIBIBIB 
BIBIBIB  IIII  IIII  IIII  IIIIBIBIBIB 
BIBIBIB  IIII  IIII  IIII  IIIIBIBIBIB 

Thoma.      Centre  part. 


Zappert-Ewing.  Thoma. 

Ik;.  13. — Blood-counting  Chambers.     (Ewing.) 

cemented  a  thinner  irlass  plate,  the  central  portion  of  which  is  cut  out.  In  this 
central  area  i-  cemented  a  circular  glass  -hell',  the  surface  of  which  is  exactly  /, 
mm.  lower  than  the  surface  of  the  glass  plate.  When  a  drop  of  diluted  blood  is 
placed  on  the  shelf  and  covered  with  a  cover-glass,  a  layer  of  fluid  i-  secured, 
which  is  exactly  T3„  mm.  deep.  Between  the  edge  of  the  shelf  and  the  surrounding 
plate  is  a  moat  into  which  the  hlood  may  run.  hut  if  the  fluid  should  run  over 
the  moat  and  beneath  the  cover-glass,  the  latter  will  he  elevated  and  the  resulting 
layer  of  fluid  will  he  more  than  ,V  mm.  deep.  The  Bhelf  is  accurately  ruled,  as 
shown   in   Pig.  13. 

The  entire  ruled   area   is  !»  sq.  mm.,  hut   only  the  central   Bquare  millimeter  i- 
u-r<\  in  counting  red  cell-,  the  others  being  required   in  counting  leucocytes.     It 


54  WOUXDS 

will  be  seen  that  this  central  square  millimeter  is  subdivided  into  400  small 
squares  (16  blocks  of  25  each),  so  that  each  small  square  is  -^  sq.  mm.  Begin- 
ning at  the  lower  left-hand  corner  of  this  area,  it  will  be  seen  that  every  fifth 
square,  above  and  to  the  right,  is  subdivided  by  an  extra  line,  which  is  added 
merely  to  assist  in  counting  the  squares.  The  outlying  square  millimeters  are  vari- 
ously ruled.  The  above  description  applies  only  to  the  so-called  "  Zappert "  cham- 
ber, which  should  always  be  secured,  preferably  of  Zeiss's  manufacture.  The  older 
chambers  cannot,  well  be  used  for  counting  leucocytes. 

Diluting  Fluids. — Of  the  various  diluting  fluids,  Toisson's  Mixture  is  to  be 
recommended : 

Sodium   sulphate    8.00  gms. 

Sodium  chloride 1.00  gm. 

Glycerin  pur 30.00  gms. 

Aq.    dest 160.00      « 

Methyl  violet    0.25  gm. 

This  fluid  keeps  well,  stains  the  leucocytes,  and  is  of  high  specific  gravity,  so 
that  the  red  cells  settle  from  it  slowly. 

When  counting  leucocytes  only,  one  may  use  with  advantage  a  0.6  per  cent 
solution  of  sodium  chloride  tinged  with  gentian  violet  (about  one  drop  of  satu- 
rated alcoholic  solution  gentian  violet  to  50  c.c.  of  salt  solution).  This  fluid,  while 
readily  prepared,  does  not  keep  well,  and  the  red  corpuscles  settle  from  it  so  rap- 
idly that  it  ought  not  to  be  used  in  counting  these  cells.  It  permits,  however,  of 
the  identification  of  eosinophile  cells  and  of  certain  degenerative  changes  in  leu- 
cocytes. 

A  reliable  fluid  for  diluting  and  permanently  preserving  blood  is  found  in 
Hayem's  Mixture : 

Hydrarg.  bichlor 0.5  gm. 

Sod.  sulphat 5.0  gms. 

Sod.  chlor 1.0  gm. 

Aq.  dest 200.0  gms. 

Directions  foe  Using  the  Hematocytometee. —  (a)  Filling  the  Pipette. — 
The  finger  tip  of  the  patient  is  cleansed  with  soap  and  water,  dried  with  alcohol, 
and  freely  punctured  with  a  needle  or  a  specially  prepared  acne  lancet.  Using 
very  gentle  pressure  only,  a  compact  drop  of  blood  is  then  expressed  and  the 
capillary  tube  is  filled  to  the  mark  1  or  0.5.  In  doing  this  the  pipette  must  be 
held  between  the  tbumb  and  forefinger  and  the  hand  steadied  against  the  hand 
of  the  patient.  In  well-constructed  pipettes  the  column  of  blood  is  easily  con- 
trolled, and  after  filling  the  end  of  the  tube  may  be  cleansed  of  adherent  blood. 
The  diluting  fluid  is  then  sucked  up  to  the  mark  101,  taking  care  that  no  blood 
runs  out  of  the  tube  when  it  is  immersed  in  the  fluid.  The  specimen  is  then  thor- 
oughly mixed  by  shaking. 

(b)  Filling  the  Counting-chamber. — The  counting-chamber  and  cover-glass  are 
thoroughly  dried  and  freed  from  particles  of  dust.  One  or  two  drops  of  diluted 
blood  are  first  forced  from  the  pipette,  and  the  third  drop,  the  size  of  which  can  be 
learned  only  by  experience,  is  deposited  on  the  central  shelf.     The  cover-glass  is 


HEMORRHAGE  56 

thru  immediately  adjusted,  slipping  one  corner  under  the  forefinger  of  the  lefi 
hand  and  controlling  the  opposite  corner  with  the  Becond  finger  of  the  righl  hand, 

mikI  lowering  the  glass  slowly  so  as  nol  t<>  include  air  bubbles.  Without  raising 
the  fingers,  now  quickly  cover  the  other  corners  with  the  forefinger  <>f  the  right 
ami  Becond  finger  of  the  left  hand,  and  press  the  cover-glass  firmly  into  position. 
If  tlir  application  is  successful  ami  no  dust  particles  have  intervened,  Newton's 
color  rings  will  appear  beneath  the  cover-glass.  The  formation  and  permanency  of 
.these  rings  may  be  facilitated  by  breathing  very  gently  on  tin;  specimen  before 
applying  tin'  cover-glass. 

The  specimen  should  m»w  he  held  up  to  the  lighl  and  examined  closely  t" 
tluit   the  red  tells  are  evenly  distributed.     An   uneven  distribution   is   readily  de- 
tected by  the  naked  eye.    After  settling  a  few  moments,  tin'  specimen  is  ready  tor 
counting. 

The  rapid  and  successful  adjustment  <>f  the  cover-glass  is  the  most  important 
detail  in   the  process  of  <<>niilin<j  blood  cells.     The  cover-glass  must   he   rapidly 

adjusted,  because  from  the  moment  the  drop  is  placed  upon  the  shelf  there  is  a 
rain  id'  tells  upon  the  ruled  area  out  of  a  layer  of  fluid  which  is  more  than  ,'„  nun. 
deep. 

'i'he  specimen   must  he  discarded  : 

if  Newton's  rings  do  not  appear: 

if  any  air  bubbles  are  inclosed  ; 

if  the  fluid  runs  underneath  the  cover-glass; 

if  the  shelf  is  not  well  covered  by  fluid; 

if.  on  inspection,  the  cells  are  found  unequally  distributed. 
(r  )  Counting  the  lied  Cells. — The  specimen  proving  satisfactory,  the  count 
may  begin  as  soon  as  the  cells  have  settled.  Zeiss.  1 )..  Leitz,  No.  ?.  Reichert's  <>r 
Bauscb  and  Lomb,  ',.  are  the  lenses  best  suited  for  this  purpose,  and  a  good 
mechanical  stage  is  necessary  for  accurate  work.  Locate  in  the  field  the  lower 
left-hand  block  of  25  small  squares,  begin  at  the  lower  and  left  square  ami  pass- 
ing to  the  righl  count  all  the  cells  lying  in  the  first  live  squares.  The  fifth  square 
will  he  found  suhdivided.  In  each  square  count  all  the  cells  lying  on  the  lower 
and  left  side  lines,  leaving  to  he  counted  with  the  adjacent  squares  all  the  squares 
lying  on  the  lines  idmve  and  to  the  right.  Proceed  in  this  way  until  at  least  four 
blocks  of  25  small  squares  and  at  least  1,000  cells  are  enumerated.  The  more 
squares  counted  over,  the  greater  the  accuracy,  and  when  slight  variations  are  to 
he  demonstrated  the  entire  square  millimeter  must  be  covered.  If  the  cells  now 
appear  to  he  unevenly  distributed,  the  specimen  should  be  discarded  and  another 
prepared   after  thoroughly   shaking  the    pipette. 

(d)  Computation. — Suppose  the  1,280  cells  are  enumerated  in  100  small 
squares — i.e..  in  one  fourth  of  the  square  millimeter.  This  Dumber  multiplied 
by  I  gives  the  number  lying  over  1  s<|  mm.  But  the  depth  of  the  fluid  is  only 
,'„  mm.,  so  thai  we  multiply  again  by  10  to  get  the  number  of  cells  in  one  cubit 
millimeter  of  fluid.  Finally,  we  must  multiply  by  100  because  the  blood  is  diluted 
in  the  proportion  of  1  :  100. 

In  short,  after  counting  oveT  100  Bmall  squares  the  result  is  multiplied  by 
4,000  to  give  the  number  of  cells  per  cubic  millimeter  ( 1  \  lo  \  100  =  4,000). 

If  the  capillary  tube  was  originally  tilled  to  the  mark  0.5,  the  dilution  is  1  :  200, 
and  the  multiplier  8,000.    If  400  squares  are  counted  over,  the  multiplier  is  ;.""". 


56  WOUNDS 

(e)  Sources  of  Error  in  the  Hematocytometer. — 1.  In  Securing  the  Drop  of 
Blood. — When  much  pressure  is  employed  in  expressing  the  drop  of  blood,  tissue 
fluids  are  squeezed  out  with  the  blood  and  the  number  of  red  cells  is  reduced. 
Eeinert  found  a  reduction  of  722,000  from  this  cause,  which  is  especially  potent 
in  cases  of  dropsy  and  of  severe  anemia. 

When  the  finger  is  cold,  the  circulation  poor,  or  local  stasis  is  produced,  as 
by  a  ligature,  the  red  cells  are  increased  in  number.  To  avoid  errors  of  this 
class,  the  circulation  in  the  hand  should  be  as  active  as  possible,  the  finger  warm, 
and  the  puncture  liberal  enough  to  permit  the  flow  of  blood  with  little  pressure 
applied  at  some  distance  from  the  puncture.  Unless  these  conditions  can  be 
secured,  it  is  hardly  worth  while  to  count  the  blood  cells. 

2.  In  diluting  the  blood  and  in  transferring  it  to  the  counting -chamber  there 
are  numerous,  plainly  evident,  sources  of  error,  such  as  the  inaccurate  filling  of 
the  capillary  tube,  the  entrance  of  air  with  the  blood  column,  the  failure  to  cleanse 
the  tip  of  adherent  blood,  the  escape  of  blood  into  the  diluting  fluid,  the  over- 
filling of  the  bulb  with  diluting  fluid,  the  inadequate  mixture  of  the  blood,  the 
failure  to  discharge  one  or  two  drops  before  applying  one  to  the  shelf,  the  use 
of  thin  cover-glasses,  and,  above  all,  delay  and  inaccuracy  in  adjusting  the  cover- 
glass.    A  little  experience  and  constant  care  serve  to  eliminate  all  these  difficulties. 

3.  In  the  Construction  and  Condition  of  the  Apparatus. — The  tendency  to 
favor  the  Zeiss  instruments  is  still  probably  well  founded,  although  Leitz  and 
Eeichert  are  now  making  very  excellent  pipettes  after  Grawitz's  model.  Aside 
from  inaccuracies  in  the  graduation  of  the  pipette  and  construction  and  ruling  of 
the  counting-chamber,  which  are  now  reduced  to  a  minimum,  some  pipettes  are 
still  on  sale  which  are  too  short,  their  caliber  is  too  large  and  is  narrowed  at  the 
point  so  that  tubes  cannot  be  cleaned,  they  require  too  much  blood,  and  the  short 
arm  is  so  small  that  the  mark  101  comes  too  close  to  the  bulb.  Accurate  work 
cannot  be  performed  with  such  instruments.  The  worker  is  at  present  advised  to 
insist  on  having  Grawitz's  pipette  made  b}^  Zeiss,  Leitz,  or  Eeichert. 

Many  close  observers  find  that  their  pipettes  vary  with  the  temperature.  While 
accurate  information  on  this  point  is  not  at  hand,  it  is  just  as  well  to  avoid  extremes 
of  temperature  in  making  the  tests  and  in  cleaning  the  instrument.  It  has  been 
suggested  that  the  polycythemia  of  high  altitudes  is  partly  referable  to  variations 
in  the  hematocytometer  due  to  chauges  in  atmospheric  pressure,  but  this  suspicion 
has  not  been  confirmed. 

The  condition  of  the  pipette  is  of  prime  importance.  Absolute  dryness  of  the 
tube  and  bulb  is  essential.  The  collection  of  minute  water  drops  in  the  tube  and 
bulb  is  responsible  for  many  of  the  shadow  corpuscles  sometimes  seen  in  the 
counting-chamber. 

Every  few  weeks  a  pipette  should  be  cleaned  out  with  concentrated  nitric  acid. 

(/)  Cleaning  the  Apparatus. — After  using  the  pipette  the  rubber  tube  may  lie 
transferred  to  the  long  arm  and  the  remaining  fluid  expelled.  The  tube  should 
then  be  cleaned  thoroughly  with  water,  then  with  alcohol  and  ether,  or,  better, 
with  pure  ether.  It  must  be  thoroughly  dried  before  using  again.  The  counting- 
chamber  must  be  cleaned  with  water  only,  as  alcohol  and  ether  dissolve  the  cement 
under  the  shelf  and  plate. 

(g)  The  Limit  of  Error  ivith  the  II cmatocytom eter . — Lyon,  Thoma  (and  Eei- 
nert), counting  an  average  of  1,111  cells  in  100  squares  with  a  dilution  of  1:  200, 


shock  57 

found  an  average  error  of  1.82  per  cent  in  24  preparations  of  the  same  specimen, 
and  in  another  case,  counting  an  average  of  934  cells  in  inn  squares,  1  :  200  dilu- 
tion, mii  average  variation  of  2.71  per  cenl  in  r.  preparations  of  the  Bame  speci- 
men (Limbeck).  These  results  in  the  hands  of  expert*  using  special  care  indicate 
thai  a  variation  of  150,000  cells  (three  per  cent)  cannot  be  accepted  as  of  any 
significance.     More  accurate  data  are,  however,  Beldom  required  by  the  clinician. 

Leucocytosis.—  An  increase  in  the  number  of  white  cells  in  the  blood  has 
been  repeatedly  observed  after  considerable  bleeding,  bul  it  is  of  no  special 
diagnostic  significance. 

SHOCK 

Shod?  is  ;i  condition  of  depression  of  the  vital  forces  following  injuries — 
physical  shock,  sometimes  surgical  shock.  A  somewhal  similar  condition  may 
be  caused  by  terror  or  other  sudden  mental  impressions  of  a  distressing  or 
horrible  character — psychic  shock.  Shock  may  follow  slight  or  grave  injuries. 
The  severity,  duration,  and  outcome  of  shock  depends  largely  upon  the  gravity 
of  the  injury  itself,  and  partly,  also,  upon  the  physical  and  menial  condition 
of  the  individual  at  the  time  the  injury  is  received.  In  shock  following  slight 
injuries,  notably  when  the  psychic  element  predominates  over  the  physical,  the 
symptoms  may  be  confined  to  an  evanescent  feeling  of  faintness  of  short  dura- 
tion, or  to  actual  syncope,  recovered  from  quickly  or  slowly,  hut  completely, 
usually  in  seconds  or  minutes.  The  symptoms  of  shock  may  be  entirely  absent 
even  in  severe  injuries,  even  those  which  are  subsequently  fatal,  when  the 
injury  is  received  during  states  of  intense  mental  preoccupation  and  exhilara- 
tion, and  may  be  very  marked  even  after  slight  injuries,  when  the  general 
nervous  system  is  depressed  from  terror,  extreme  physical  fatigue,  or  other 
depressing  factors.  In  battle,  or  even  in  times  of  peace,  when  the  individual 
is  stimulated  by  enthusiasm  or  anger  or  other  mental  preoccupation,  the  most 
Severe  injuries  may  he  unattended  by  the  symptoms  of  shock,  either  local  or 
general.  The  individual  may,  indeed,  he  quite  unconscious  that  anv  injury 
has  been  received.  Acts  requiring  extreme  muscular  exertion  and  courage 
may  he  performed  after  the  receipt  of  severe  and  even  dangerous  wounds, 
and  the  individual  may  only  be  conscious  that  lie  is  injured  by  seeing  or  feel- 
ing the   flow  of  blood   or  from   faintness  dwi-  to   hemorrhage. 

Signs  and  Symptoms  of  Shock. — Shock  occurs,  as  will  be  noted,  very  com- 
monly after  injuries  of  the  abdominal  contents  and  after  serious  injuries  of 
the  contents  of  the  thorax  or  of  the  cranium,  as  well  as  after  serious  injuries 
ol  other  parts  of  the  body.  The  condition  appears  to  be  due  largely  to  mechan- 
ical irritation  of  the  peripheral  nerves,  with  reflex,  partial  or  complete,  paralysis 
ot  the  vasomotor  centers  of  the  medulla.  The  normal  tone  of  the  arteries 
throughout  the  body  is  lost  ;  there  is  a  suddm  and  decided  fall  of  blood  pres 
sure.  The  hear!  acts  feebly  and  irregularly,  and  the  blood  tend-  to  accumulate 
in  tho  large  veins,  notably  in  the  veins  of  the  abdomen;  while  the  lungs,  the 


58 


WOUNDS 


brain,  and  the  skin  are  anemic.  The  right  side  of  the  heart  is  sometimes 
distended  with  blood. 

The  appearance  of  an  individual  suffering  from  shock  is  fairly  character- 
istic. The  skin  and  the  mucous  membranes  are  pale.  The  surface  of  the  body 
is  cold  and  bathed  in  a  clammy  sweat.  The  features  are  pinched.  The  expres- 
sion of  the  eyes  is  dull,  and  the  pupils  are  often  dilated  and  respond  but  slowly 
to  light.  The  pulse  is  feeble,  compressible,  and  irregular,  sometimes  slow  and 
sometimes  rapid.  Kespiration  is  irregular  and  often  sighing,  shallow  respira- 
tions alternate  with  deep  sighs.  Cerebration  is  imperfect.  These  patients 
answer  questions  in  a  dull  and  stupid  manner,  and  do  not  realize  the  gravity 
of  their  condition.  Frequently  they  suffer  but  little  pain  in  spite  of  the  most 
severe  injuries.  The  body  temperature  is  often  subnormal.  There  may  be 
nausea  and  vomiting.  The  condition  of  shock  may  last  for  some  minutes 
or  for  many  hours.  (It  is  stated  by  some  authors  that  the  symptoms  of  shock 
may  not  appear  for  many  hours  after  the  injury  or  surgical  operation,  as  the 
case  may  be.  This  condition  has  sometimes  been  designated  as  delayed  shock. 
It  seems  probable  to  me  that  in  at  least  many  instances  this  condition  is  really 
due  to  an  acute  septicemia  or  to  hemorrhage  or  to  a  combination  of  these  con- 
ditions.) If  the  patient  is  to  survive,  the  symptoms  gradually  improve  either 
with  or  without  treatment.  The  action  of  the  heart  and  the  breathing  slowly 
return  to  normal.  The  skin  becomes  warm,  etc.  If  the  condition  is  a  fatal 
one,  the  patients  gradually  sink  into  a  condition  of  unconsciousness  and  die 
from  heart  failure. 

Shock  and  Hemorrhage. — Following  accidents,  surgical  operations,  and  the 
administration  of  general  anesthetics,  the  condition  of  shock  is  frequently  com- 
bined with  the  depression  caused  by  loss  of  blood  and  the  administration  of 
large  doses  of  ether  or  chloroform,  as  the  case  may  be.  In  cases  of  accident, 
hemorrhage  and  shock  are  frequently  combined,  and  it  may  not  be  easy  to 
distinguish  which  of  the  two  conditions  is  the  predominant  factor.  In  cases 
of  injury  of  the  abdomen,  for  example,  it  may  be  of  great  consequence  to  know 
whether  the  patient  is  suffering  from  shock  or  from  hemorrhage  or  from  a  com- 
bination of  both  conditions.  For  upon  the  decision  of  this  question  the  sur- 
geon must  often  be  guided  as  to  whether  he  should  open  the  abdomen  imme- 
diately or  leave  the  patient  alone,  at  least  for  a  time.  If  the  condition  has 
endured  for  some  little  time,  an  examination  of  the  blood  for  its  content  of 
hemoglobin  may  be  a  valuable  aid.  If  the  percentage  of  hemoglobin  in  the 
blood  is  notably  diminished,  it  is  at  least  probable  that  the  symptoms  are 
in  part  due  .to  loss  of  blood.  If  the  symptoms  have  occurred  immediately 
after  the  injury  and  slowly  grow  better  under  appropriate  treatment,  it  is 
probable  that  shock  is  an  important  factor  in  the  condition.  If  the  patients 
have  been  in  fair  condition  after  the  injury,  and  the  symptoms  have  only 
come  on  gradually  and  are  of  a  character  which  are  described  under  the 
head  of  Hemorrhage,  it  is  probable  that  loss  of  blood  is  the  cause  of  the 
condition. 


SHOCK  5Q 

Local   Shock. — it  has   been    repeatedly   noticed    thai    gunshol    wounds 
attended  by  more  or  less  complete  paralysis,  both   motor  and  sensory,  of  the 

injured   part,  which  may   last    for  h "a  or  days.     This  condition  gradually 

passes  away,  ;ui<l   is   followed  by  ;i   return  of  motion  and  sensation,  assuming 

thai   ii"  large  nerve  trunk   is  injured,  n<>  large  M l-vessel   divided,   no  body 

cavity  opened,  nor  any  other  essentially  seriou9  complication  has  occurred. 


CHAPTER    II 

THE   DIAGNOSIS   OF  THE   DISEASES  CAUSED   BY  THE  PUS-PRODUCING 

BACTERIA 

VARIETIES    OF    PUS-PRODUCING    ORGANISMS 

Before  describing  in  detail  the  local  and  general  disturbances  produced 
in  the  human  body  by  the  pyogenic  bacteria,  it  will  be  desirable  to  consider: 
(1  )  Some  of  the  general  and  special  characters  of  these  organisms;  (2)  their 
occurrence  in  the  body  under  normal  conditions;  (3)  the  avenues  whereby  they 
gain   an  entrance   to  the  body. 

In  speaking  of  certain  specific  infectious  diseases  (Chapter  III)  we  have 
noted  that  the  effects  produced  by  inoculation  with  tetanus  bacilli,  etc.,  are 
fairly  constant,  and  that  following  such  inoculation  we  may  predict  with  cer- 
tainty the  character  of  the  local  and  general  symptoms  which  are  to  follow. 
Such  is  not  the  case  with  the  pyogenic  bacteria ;  their  effects  are  very  varied. 
A  great  variety  of  disturbances  may  be  produced  by  the  same  organism  under 
different  conditions,  and  several  kinds  of  bacteria  are  capable  of  producing 
the  same  pathological  changes.  For  example,  any  one  of  several  varieties  may 
produce  purulent,  serous,  or  fibrinous  inflammations,  and  may,  under  suit- 
able conditions,  cause  such  varied  lesions  as  furuncle,  osteomyelitis,  purulent 
peritonitis,  septicemia,  or  pyemia.  Although  a  good  many  varieties  of  bac- 
teria may  cause  suppuration  under  special  conditions,  yet  there  are  certain 
ones  which,  on  account  of  their  regular  association  with  these  processes,  are 
to  be  regarded  as  the  pus-producing  organisms  par  excellence.  These  are: 
(1)  Staphyloccus  pyogenes  aureus;  (2)  Staphylococcus  pyogenes  albus;  (3) 
Staphylococcus  pyogenes  citreus ;  (4)  Staphylococcus  pyogenes  cereus  albus 
and  flavus;  (5)  Streptococcus  pyogenes;  (6)  Varieties  of  Streptococcus  pyo- 
genes, also  Bacillus  pyocyaneus;  (7)  Micrococcus  tetragenus;  (8)  Bacillus  coli 
communis. 

Staphylococcus  pyogenes  aureus  is  a  micrococcus  of  irregular  size,  of  an 
average  diameter  of  0.9  fi,  arranged  irregularly  in  masses. 

This  bacterium,  which  is  nonmotile,  grows  on  gelatin  plates  in  minute  colonies, 
apparent  under  a  low  power  of  the  microscope  after  twenty-four  hours,  granu- 
lated on  the  surface,  and  of  a  brownish  color.  The  colonies  gradually  become 
visible  to  the  naked  eye  as  whitish-yellow  points,  which  later  become  more  dis- 
tinctly golden  yellow.  Liquefaction  of  the  gelatin  occurs  around  them,  and  a 
60 


VARIETIES    OF    I'l  s  I'KoDiri.M,    ORGANISMS  61 

funnel-shaped  depression  appears,  :it  the  bottom  <>l'  which  are  the  colonies.  In 
needle  cultures  in  gelatin  the  line  of  development  appears  along  the  needle  track 
(in  the  day  after  inoculation,  and  on  the  second  or  third  day  the  beginning 
liquefaction  may  be  noted  at  the  upper  portion.  The  liquefaction  progresses  -lowly 
at  the  lower  portion  of  the  culture,  more  rapidly  at  the  upper  pari  ;  as  it  incn 
the  main  portion  of  the  colony  falls  to  the  bottom  as  a  fiocculenl  deposil  which 
take-  on  a  golden-yellow  color,  while  the  liquefied  portion  remain-  turbid;  finally, 
in  the  course  of  from  one  to  two  weeks  the  gelatin  becomes  entirely  Liquefied 
out  to  the  wall  of  the  tube.  <)n  agar  the  colonies  develop  along  the  needle 
track  as  an  ahundant.  moist,  shining  growth,  which  is  well  marked  after  twenty- 
four  hours  at  the  temperature  of  the  body.  It  later  takes  on  the  golden-yellow 
color,  which  may  he  well  marked  at  the  end  of  Eorty-eight  hours.  <>n  potato  it 
grows  well,  producing  an  abundant  layer  that  also  assumes  a  golden-yellow  color. 
In  bouillon  it  produces  a  uniform  cloudiness,  which  later  sinks  to  the  bottom, 
with  a  brownish-yellow  color.  It  coagulates  milk,  produces  an  acid  reaction  in 
the  various  media,  does  not  produce  spores,  although  it  retains  its  vitality  in  old 
cultures  for  a  considerable  length  of  time,  and  requires  rather  a  higher  temperature 
for  its  destruction  than  most  nonspore-bearing  hacteria  (according  to  Luhhert, 
needing  a  temperature  of  80°  C.  for  half  an  hour).  It  stains  readily  with  any 
of  the  anilin  colors,  and  by  Gram's  method. 

Pathogenic  Properties. — Injections  of  small  amounts  of  pure  culture  are  usu- 
ally not  followed  by  any  results;  but  large  amounts,  or  intravenous  or  intra- 
abdominal injections,  arc  usually  followed  by  fatal  results  in  rabbits  or  guinea 
pigs  in  a  few  days,  with  minute  abscess  formation  in  the  k?dneys  especially. 

The  Staphylococcus  pyogenes  albus  is  a  micrococcus  less  virulent  than  the 
preceding,  whose  characteristics  are  precisely  the  same  with  the  exception  that  its 
colonies  are  white  and  not  colored. 

The  Staphylococcus  epidermis  albus  of  Welch  is  probably  but  a  variety  of  the 
preceding,  occurring  in  the  deeper  layers  of  the  skin. 

A  third  micrococcus  of  pus,  much  less  common  than  either  of  these  two.  is 
the  Staphylococcus  pyogenes  citeeus,  differing  from  the  others  in  that  its 
colonics  arc  of  a  lemon  yellow,  and  the  fact  that  its  pathogenic  properties  are 
very  .-light. 

The  Staphylococcus  ckreus  albus  and  the  Staphylococcus  ceeeus  flavus 
are  of  practically  no  importance.  They  are  found  occasionally  in  suppurative  proc- 
esses. They  do  not  liquefy  gelatin;  the  one  produces  a  white  waxy  growth  upon 
ordinary  media,  while  the  other  produces  a  yellow  waxy  growth.  They  have  not 
been  shown  to  have  any  special  pathogenic  properties. 

The  .Streptococci's  pyogenes  is  a  coccus  of  a  somewhat  larger  average  size 
than  the  staphylococcus,  being  about  1  /x  in  diameter,  occurring  in  chains  whicih 
may  be  made  up  of  a  large  or  of  a  small  number  of  cells.  Sometimes  there  is 
the  appearance  of  a  chain  of  diplococci,  because  the  division  of  many  individual 
members  of  the  chain  may  he  going  on  at  the  same  time.  In  young  cultures  the 
micrococci  are  uniform  in  size:  hut  as  they  grow  older  a  marked  difference  appear-, 
some  of  the  individuals  being  twice  the  normal  diameter  and  more.  This  strepto- 
coccus is  nonmotile.  On  cultivation  in  gelatin  a  very  thin  line  appear-  along  the 
needle  track,  which  is  seen  to  he  made  up  of  a  row  of  minute  round  colonies, 
whitish  in  color,  rarely  reaching  the  size  o{  a  pin's  head.     There  i<  no  growth  on 


62        DISEASES    CAUSED   BY   THE   PUS-PRODUCING  BACTERIA 

the  surface  of  the  gelatin,  and  no  liquefaction  or  color  production.  In  gelatin 
plates  the  colonies  also  appear  as  minute  whitish  globular  points,  flat  and  trans- 
lucent upon  the  surface.  On  the  surface  of  agar  the  growth  takes  place  along 
the  needle  track  as  minute  rounded  colonies,  showing  a  marked  tendency  to 
remain  separate.  The  characteristics  upon  blood  serum  are  the  same  as  upon 
agar;  on  potato  there  is  generally  no  visible  growth;  in  bouillon  there  is  appar- 
ent a  very  fine  cloudiness,  which  later  settles  to  the  bottom  of  the  tube.  It 
coagulates  milk,  and  is  said  occasionally  to  produce  gas  in  sugar  media  and  to 
turn  litmus  red.  It  grows  best  at  the  temperature  of  the  body,  and  with  a 
fair  degree  of  rapidity.  It  does  not  produce  spores,  does  not  liquefy  gelatin,  and 
produces  no  pigment.  It  stains  with  any  of  the  anilin  colors  and  by  Gram's 
method.  Inoculated  into  the  ear  of  a  rabbit,  it  produces  a  localized  erysipelatous 
process;  but  usually  subcutaneous  injections  in  rabbits  and  guinea  pigs  are  with- 
out result. 

It  must  be  remembered  that  one  of  two  things  must  be  true :  either  there  are 
many  kinds  of  streptococci  which  our  present  means  of  study  do  not  enable  us 
to  differentiate,  or  this  streptococcus  takes  on  many  variations  of  virulence  under 
the  influence  of  varying  surroundings. 

Varieties  of  Streptococci. — It  may  be  stated  that  formerly  the  Streptococcus 
pyogenes  and  the  Streptococcus  erysipelatis  were  regarded  as  two  distinct  species, 
and  various  points  of  difference  between  them  were  given.  Further  study,  and 
especially  the  results  obtained  by  modifying  the  virulence,  have  shown  that  these 
distinctions  cannot  be  maintained,  and  now  nearly  all  authorities  are  agreed  that 
the  two  organisms  are  one  and  the  same,  erysipelas  being  produced  when  the  Strep- 
tococcus pyogenes  of  a  certain  standard  of  virulence  gains  entrance  to  the  lym- 
phatics of  the  skin.  Petruschky  in  1896  showed  conclusively  that  a  streptococcus 
cultivated  from  pus  may  cause  erysipelas  in  the  human  subject. 

There  is  occasionally  found,  in  the  study  of  surgical  lesions,  a  bacterium  that 
produces  a  striking  greenish-blue  fluorescence  in  the  nutrient  media  on  which  it 
grows.  This  is  the  Bacillus  pyocyaneus  which  is  of  interest  not  because  it  pro- 
duces any  pathological  changes,  but  by  reason  of  the  studies  that  have  been  made 
upon  the  pigment  which  it  produces,  and  its  apparently  augmenting  effect  when 
inoculated  at  the  same  time  with  certain  other  micro-organisms.  It  is  one  of  a 
number,  and  the  characteristics  of  the  group  are  best  studied  in  the  large  text- 
books. 

The  Micrococcus  tetragexus  is  also  an  organism  which  rarely  occurs  in  sur- 
gical lesions,  characterized  especially  by  the  fact  that  it  divides  in  two  planes  at 
right  angles  to  one  another,  so  that  it  is  frequently  found  in  the  tissues  after 
inoculation  in  groups  of  four,  sometimes  surrounded  by  a  capsule.  The  bacilli 
stain  easily  with  all  the  ordinary  stains,  as  well  as  by  Gram's  method.  This  micro- 
coccus is  about  1  fx,  in  diameter.  It  grows  readily  in  gelatin  plates,  as  round, 
yellowish-white  colonies,  which  appear  granular  or  slightly  nodulated  under  a  low 
power.  The  surface  colonies  show  the  yellowish-white  color  more  markedly.  The 
needle  culture  in  nutrient  gelatin  gives  a  fairly  thick  whitish  line  along  the  track 
of  the  needle,  with  a  round,  thick,  yellowish-white  disk  on  the  surface.  The  organ- 
ism grows  abundantly  on  the  surface  of  agar  and  of  potato,  in  a  moist  layer  of 
a  yellowish-white  color.  It  grows  rapidly  at  the  temperature  of  the  room,  does 
not  produce  spores,  and  does  not  liquefy  gelatin.     It  is  especially  pathogenic  to 


VARIETIES    OF    PUS  PRODUCING    ORGANISMS 


63 


white  mice,  a  Bubcutaneoue  injection  producing  a  general  septicemia,  the  organisms 
being  found  in  large  numbers  in  the  blood  and  tissues,  especially  the  spleen.  Thie 
micrococcus  is  supposed  t < >  be  active  in  the  production  of  the  suppurative  part 
of  the  destructive  process  in  tuberculosis  of  the  lung. 

The  Bacillus  coli  com  mix  is  Is  found  in  many  Inflammatory  and  sup- 
purative conditions  in  connection  with  the  alimentary  tract;  it  is  found  also 
in  other  parts  of  the  body,  in  inflammation  of  the  urinary  passages,  cystitis,  etc. 
It  is  a  bacillus  from  2  to  3  /<.  long  and  aboul  0.5  />.  broad,  with  rounded  ends.  It 
i.-  actively  motile,  and  grows  in  gelatin  plates  as  small  brownish-white  colonies,  uol 
Liquefying  the  gelatin.  In  nutrient  gelatin  the  growth  is  well  marked  along  tin; 
needle  truck,  as  a  whitish  line,  spreading  oui  upon  the  Burface  of  the  gelatin,  uol 
much  elevated  from  the  surface  of  the  media;  on  agar  it  ^vnw>  distinctly  oul  from 

the  needle  track,  as  a  whitish-brown  layer,  ist,  dirty  in  appearance;  the  Bame 

appearances  characterize  the  growth  on  blood  serum:  on  potato,  in  forty-eighi 
hours,  there  is  a  distinctly  brown  pellicle  with  a  dull  surface. 

The  growth  clouds  bouillon,  produces  gas  in  glucose  media,  turns  litmus  media 
red,  and  has  a  marked  indol  reaction  in  peptone  solutions.  It  grows  rapidly  | 
at  the  temperature  oi'  the  body),  floes  not  produce  spores,  does  not  liquefy  gelatin, 
produces  gas,  and  stains  with  any  of  the  anilin  colors,  hut  not  hv  Gram's  method. 
Intravenous  injection  of  small  amounts  in  guinea  pigs  will  produce  death,  hut 
much  larger  amounts  are  required  to  produce  the  same  results  in  rabbits  or  guinea 
pigs  alter   intra-abdominal   injection. 

Muir  and  Ritchie  give  the  following  table  of  differences  between  the  Bacillus 
typhosus  and  the  Bacillus  coli  communis: 


B.  Typhosus 

Flagella  more  numerous,  longer  and 
more  wavy. 

In  artificial  media  the  growth  is  gen- 
erally slow  and  not  vigorous. 

Growth  on  fresh  acid  potatoes  a  nearly 
transparent   film. 

Very  slighl  acid  production  in  ordinary 
media,  followed  sometimes  hv  the  pro- 
duction of  alkali. 

Fermentation  of  lactose  very  slight,  if 
any. 

Milk  not   coagulated. 

In    gelatin    '•shake"    cultures    no    gas 

•    formation. 

No  production  of  indol  in  ordinary 
bouillon. 

WidaTs  reaction.  Bacilli  become 
clumped  together  and  motionless  in 
the  serum  of  a  typhoid  patient.  (  A 
similar  reaction  is  given  by  the  blood 
serum  of  an  animal  immunized 
against  the  typhoid  bacillus.) 


B.  Coli  ( 'omniums 
Flagella  fewer  and  shorter. 

Growth  faster  and  more  vigorous. 

Growth  on  potatoes  a  brown  pellicle. 

Well-marked  acid    production. 

Fermentation  pronounced. 

Milk  coagulated. 

Abundant  gas  formation.  Rounded  col- 
onies. 

Well-marked  indol  production.  In 
some  varieties  cone  (  Klein  ). 

Bacilli  remain  actively  motile. 


64        DISEASES    CAUSED   BY   THE   PUS-PRODUCING   BACTERIA 

Of  the  bacteria  already  mentioned,  the  staphylococci  are  most  commonly 
found  in  localized  abscesses  or  pustules,  carbuncles,  boils,  in  acute  suppurative 
periostitis,  in  ulcerative  endocarditis,  and  in  certain  pyemic  conditions.  The 
streptococci  are  usually  found  in  spreading  inflammations  with  or  without 
suppuration,  in  diffuse  phlegmonous  and  erysipelatous  conditions,  in  suppura- 
tions in  certain  membranes,  and  in  joints.  The  Bacillus  coli  communis  is 
found  in  many  inflammatory  and  suppurative  conditions  in  connection  with 
the  alimentary  tract  and  elsewhere.  The  Micrococcus  tetragenus  is  found  espe- 
cially in  suppurations  in  the  region  of  the  mouth  or  neck,  as  well  as  in  various 
lesions  of  the  respiratory  tract.  The  Bacillus  pyocyaneus  is  rarely  found  alone 
in  pus. 

The  Gonococcus  is  a  constant  accompaniment  of  that  specific  form  of  suppura- 
tion known  as  gonorrhea.  Its  special  characteristic  is  that  it  is  a  micrococcus 
occurring  most  commonly  in  pairs,  with  the  adjacent  edges  flattened  or  even 
slightly  concave.  Another  of  its  marked  characteristics  is  that  it  most  commonly 
occurs  in  the  leucocytes,  which  is  different  from  what  is  the  case  in  ordinary  sup- 
puration. It  stains  easily  and  well  with  any  of  the  ordinary  dyes,  but  does  not 
stain  by  Gram's  method.     (See  also  Gonorrhea.) 

JSTeisser's  stain  gives  very  beautiful  results.  Cover-glasses  in  warm  concentrated 
alcoholic  eosin,  two  to  three  minutes.  Transfer  directly,  after  soaking  off  excess 
with  filter  paper,  to  concentrated  alcoholic  methylene  blue  for  one  half  to  three 
quarters  of  a  minute.  Wash  in  water,  dry,  and  mount.  (These  times  of  staining 
have  been  found  to  be  better  than  those  originally  given.) 

The  cultivation  of  the  gonococcus  is  difficult.  It  does  not  grow  upon  the  ordi- 
nary media.  The  best  are  solidified  blood  serum  and  Wertheim's  medium,  con- 
sisting of  one  part  of  fluid  serum  and  two  parts  of  agar  at  a  temperature  of  40°  C, 
which  is  then  allowed  to  solidify  by  cooling.  Growth  occurs  best  at  the  temperature 
of  the  body,  and  does  not  go  on  below  25°  C.  The  cultures  are  to  be  obtained  by 
passing  a  small  quantity  of  pus  over  the  surface  of  one  of  the  selected  media,  and 
then  placing  it  in  an  incubator.  The  colonies  make  their  appearance  at  the  end 
of  twenty-four  hours  as  small  translucent  bodies,  irregularly  rounded,  and  reach 
their  maximum  size  on  the  fourth  or  fifth  day.  The  later  cultures  grow  more 
luxuriantly  than  do  the  earlier  ones,  but  the  transference  to  fresh  media  must  be 
made  every  two  or  three  days. 

Diplococcus  pneumonia  (Frankel's  pneumococcus ;  Microbe  of  Sputum  sep- 
ticemia; Micrococcus  Pasteuri;  Diplococcus  lanceolatus) . — Under  these  headings 
may  be  placed  a  description  of  the  diplococcus  that,  while  not  usually  producing 
primary  surgical  results,  may  often  occur  associated  with  the  pyogenic  cocci.  It 
is  of  grave  importance  in  medicine.  It  occurs  not  infrequently  in  the  saliva  of 
healthy  persons,  with  great  abundance  in  the  expectoration  of  certain  forms  of 
pneumonia,  and  has  been  studied,  associated  with  the  septic  cocci. 

The  best  method  of  securing  a  pure  culture  is  that  of  subcutaneous  inocula- 
tion of  material  containing  it  in  rabbits  or  guinea  pigs;  in  which  case  the  ani- 
mals will  die  in  from  twenty-four  to  forty-eight  hours,  and  the  blood  and  tissues 
will  be  found  to  be  filled  with  this  micro-organism.  It  is  an  oval  coccus,  occur- 
ring usually  in  pairs,  and  may  be  surrounded  by  a  capsule.  The  colonies  are  not 
apparent  upon  ordinary  gelatin  plates  or  in  gelatin  tubes,  for  the  reason  that  the 
bacterium  does  not  grow  below  22°  C,  so  that  cultures  are  best  seen  after  develop- 


VARIETIES    01    PUS  PRODUCING    OROANIS 

nielli  iipon  agar  at  the  temperature  of  the  blood.     In  this  case  the  colon  • 
as  minute,  almost   transparent   drops,   looking  almosi   like  Bmall  drops  of  water. 
The}  gro^  best  upon  blood  Berum,  .1-  an  almosl  transparent  line  along  the  o< 
track,  wnli  isolated  colonies  al   the  edges,  later  becoming  more  <>r  less  confluent. 
The  colonies  on  agar  plates  are  almosl  invisible,  bul  may  !>•■  Been  by  means 
low-power  lens,  and  appear  to  have  a  compact,  finely  granulated  center,  with  almost 
translucent  edges.    There  is  a  alight  cloudiness  produced  in  bouillon,  which  later 
Bettles  to  the  bottom  of  the  test-tube.    There  is  m>  visible  growth  upon  potato.     It 
is  very  difficult  to  keep  the  cultures  alive,  and  to  do  so  they  must  be  renewed  every 
three  or   four  days,  and   even   then   are   fairly   certain    t<>  die  out    in   the  conn 
two  or  three  months.     It  is  impossible  to  retain  the  virulence  of  the  micro-organism 
under  cultivation.    This  must  he  done  by  the  pa--   a         ough  animals.     Its  growth 
is   slow   except    at    the   temperature  of   the  body.      It    does   not    produce   sp.       -. 
not  liquefy  gelatin,  doe-  not  produce  gas,  i-  facultatively  anaerobic,  stain-  with  the 
ordinary  dyes  and  by  Gram's  method,  and  produce-  septicemia  upon  subcutaneous 
inoculation. 

Malignant  Edema. — This  disease  occurs  in  human  beingB  as  a  spreading  in- 
flammatory edema,  accompanied  by  emphysema,  and  later  followed  by  gangrene 
of  the  skin  and  adjacent  parts.  The  disease  i-  produced  by  the  bacillus  of  malig- 
nant edema,  first  described  by  Pasteur  as  the  "  vibrion  septuple."  Like  the  bacillus 
of  tetanus,  this  bacillus  is  present  not  uncommonly  in  garden  soil,  manure,  ami 
various  putrefying  fluids.  It  is  rather  a  large  bacillus,  occurring  in  rods  from  3 
to  ]o  /(  long,  not  infrequently  growing  out  into  long  filaments,  hut  on  solid  media 
generally  occurring  as  short  rods  with  somewhat  rounded  ends.  It  is  motile,  with 
fiagella  placed  on  the  sides.  It  forms  Bpores,  which  are  present  usually  at  about 
the  center  of  the  rod.  As  this  bacillus  develops  only  under  anaerobic  conditions, 
it  may  he  differentiated  by  this  fact  alone  from  the  anthrax  bacillus,  which  it 
somewhat  resembles  under  the  microscope. 

In  gelatin  plates,  under  anaerobic  conditions,  the  colonies  appear  as  small  whit- 
ish points,  which  under  a  low  power  show  radiating  appearances  soon  masked  by  a 
zone  of  Liquefaction.     In  deep  tubes  of  glucose-gelatin  the  growth  appears  as  a 
whitish   line,  giving  off  minute  short  processes,  never  reaching  within  an  inch  of 
the   top  of  the   medium,   with   the  occurrence  of  liquefaction   and    the   settling 
the  colonies  to  the  bottom.     In  deep  tubes  of  glucose-agar  at  a   temperature  of 
31      I '.  the  growth  is  very  rapid,  as  a  broad  white  line  along  the  line  of  puncture, 
with   lateral    projections  here   and    there,  and   a   very  profuse   production   of    _   - 
Tin1  cultures  have  a  peculiar  heavy  odor  that  is  quite  characteristic.     The  growth 
is  rapid:  it  produces  spores  that  are  well  seen  within  forty-eight  hour-  a;   31     I 
it    produces  gas.  liquefies  gelatin,  and   stain-  easily  with  any  of  the  anilin  colors, 
hut  not  by  Gram's  method:  upon  subcutaneous  inoculation  in  any  susceptible  ani- 
mal it  produces  the  characteristic  symptoms  of  widespread  edema,  gas  production, 
and  gangrene. 

For  purposes  of  diagnosis,  the  microscope  is  not  particularly  useful,  for.  micro- 
scopically, tin'  bacillus,  unless  in  the  stage  of  spore  production,  doe-  not  poss  38 
characteristics  sufficient  to  identify  it.  Culture-  may  he  made  in  glucose-gelatin 
as  roll-cultures,  and  kept  under  anaerobic  conditions.  If  the  bacilli  contain  sp 
the  fluid  tan  he  kept  at  a  temperature  of  Sir"1  ('.  for  ten  minutes,  and  then  a  <]oop 
glucose-agar  tube  should  he  inoculated  and  kept  at  the  temperature  o(  the  body. 
1; 


66         DISEASES    CAUSED    BY    THE    PUS-PRODUCTXG   BACTERIA 

An  inoculation  experiment  with  the  suspected  material  may.  also  be  tried  in  guinea 
pigs. 

Bacillus  aerogexes  capsulatus  *   (see  page  95). 

METHODS  OF  OBTAINING  AND  CARING  FOR  PATHOLOGICAL  MATERIAL 

In  surgical  work  it  is  customary  and  necessary  to  leave  the  actual  identi- 
fication of  the  bacteria  found  in  exudates  and  organs  to  the  pathologist,  and 
for  the  technic  of  such  procedures  the  reader  is  referred  to  works  on  surgical 
bacteriology.  A  few  remarks  on  the  precautions  to  be  adopted  by  the  surgeon 
in  collecting  and  transferring  materials  to  the  pathologist  may  not  be  amiss. 
The  materials  should  be  transferred  without  loss  of  time.  Xothing  should  be 
brought  in  contact  with  the  bacteria  which  may  destroy  them,  such  as  anti- 
septics, nor  should  they  be  exposed  to  extremes  of  heat  or  cold.  Contamination 
with  extraneous  bacteria  must  be  avoided.  Fluids  may  be  caught  in  sterile 
test-tubes  and  plugged  with  sterile  cotton  or  they  may  be  aspirated  into  a 
pipette  and  the-  ends  of  the  pipette  sealed  in  a  flame  or  plugged  with  cotton. 

Inoculation  of  Culture-tubes.  —  A  convenient  method,  and  the  one  ordinarily 
pursued,  is  as  follows :  Two  test-tubes  are  used :  one  contains  a  sufficient  quan- 
tity of  sterile  nutrient  bouillon;  the  other  contains  a  metal  rod  tipped  with 
a  sterile  cotton  swab;  both  are,  of  course,  plugged  with  sterile  cotton.  When 
a  specimen  is  to  be  taken  the  metal  rod  is  removed,  plunged  into  the  exudate 
until  the  cotton  swab  upon  its  end  is  thoroughly  smeared  with  the  material 
to  be  examined;  the  cotton  plug  is  then  removed  from  the  tube  containing 
the  nutrient  bouillon ;  the  rod  is  then  introduced  into  this  tube,  and  the  infected 
cotton  swab  is  agitated  for  an  instant  in  the  bouillon.  The  rod  is  then  re- 
placed in  its  tube  and  the  cotton  plug  along  with  it ;  the  tube  containing  the 
bouillon  is  again  plugged  with  cotton.  The  cotton  is  ignited  for  an  instant 
in  a  flame  and  then  blown  out,  and  both  tubes  are  then  sent  to  the  pathological 
department  for  microscopic  examination,  cultivation  of  the  bacteria  contained 
in  the  bouillon,  and  inoculation  experiments,  if  such  prove  necessary.  The 
character  of  the  nutrient  medium  may  be  varied  to  suit  special  conditions. 

Organs  for  Bacteriological  Examination. — Organs  for  bacteriological  exami- 
nation are  sent  without  delay.  In  order  to  examine  the  interior  of  an  organ 
bacteriologically,  the  surface  may  be  seared  with  a  cautery  iron  and  a  cut  made 
through  the  seared  surface  with  a  sterile  knife ;  cultures  and  microscopic  exami- 
nations may  then  be  made  from  the  cut  surface. 

VARYING    SEVERITY    OF    PYOGENIC    INFECTIONS 

While,  as  has  been  stated,  the  activities  of  the  several  varieties  of  pus- 
producing  germs  are  more  or  less  similar,  yet,  from  a  practical  point  of  view, 

1  The  above  details  in  regard  to  pyogenic  bacteria  are  largely  quoted  from  H.  C.  Ernst, 
"International  Text-Book  of  Surgery."     Warren  Gould. 


PATHOLOGICAL   CHARACTER    01    PYOGENK      BACTERIA 

ii  is  l>v  no  mean-  a  matter  of  indifference  whether  a  given  inflammation  baa 
been  caused  by  one  or  the  other  of  Beveral  germs.  For  example,  a  purulent 
peritonitis  caused  by  Streptococcus  pyogenes  is  apt  to  be  much  more  Berious 
than  one  in  which  the  colon  bacillus  alone  is  active.  Again,  we  know  that 
Staphylococcus  albus  is  a  germ  producing  less  virulent  forms  of  suppuration 
than  Staphylococcus  aureus.  There  seems  also  to  be  more  ri-k  of  contaminat- 
ing other  patients  from  streptococcus  infections — witness  the  unusually  con- 
tagious quality  oi  erysipelas  and,  in  general,  a  necessity  for  more  vigorous  local 
and  general  measures  in  the  treatment  of  these  <■. 

PATHOLOGICAL   CHARACTER   OF    PYOGENIC    BACTERIA 

The  different  forms  of  pyogenic  bacteria  possess  fairly  definite  patholog- 
ical characters,  to  be  now  briefly  considered:  Staphylococcus  pyogenes  aureus  is 
most  commonly  concerned  in  the  production  of  boils,  carbuncles,  circumscribed 
abscesses,  acute  suppurative  periostitis  and  osteomyelitis,  ulcerative  endocar- 
ditis, in  some  cases  of  purulent  peritonitis,  and,  at  present,  many  observers 
believe  that  pyemic  infections  are  more  commonly  caused  bv  this  germ  than 
any  other.  The  Streptococcus  is  especially  concerned  in  the  production  of 
spreading  local  inflammations,  often  with  the  production  of  necrosis  of  tissue, 
with  or  without  pus,  in  phlegmonous  proa  --  -  _  nerally,  in  erysipelas,  and  in 
suppurating  joints,  in  had  forms  of  puerperal  infection,  and  in  the  worst  forms 
of  purulent  peritonitis  and  peritoneal  sepsis.  The  streptococcus  a  -  vary 
greatly  in  virulence,  and  the  source  of  the  streptococcus  producing  an  infec- 
tion has  a  marked  hearing  on  the  result.  For  example,  streptococci  are  found 
commonly  enough  on  the  healthy  mucous  membrane  of  the  mouth  and  throat, 
and  in  this  situation  may  possess  very  slight  decrees  of  virulence.  When 
taken  from  a  case  of  phlegmonous  erysipelas  or  puerperal  septicemia  the  viru- 
lence of  this  germ  is,  on  the  other  hand,  oftentimes  of  fearful  potency. 

The  Staphylococci,  other  than  Staphylococcus  pyogenes  aureus,  appear  to 
have  similar  pathological  characters  to  Staphylococcus  aureus,  hut  they  are 
generally  notably  less  virulent.  The  white  staphylococcus,  as  was  pointed  out 
by  Welch,  is  a  regular  inhabitant  of  the  human  skin — notably  of  the  hair  folli- 
cle- and  sweat  glands — so  that  it  cannot  he  destroyed  by  ordinary  means,  and 
may  give  rise  to  stitch  abscesses  after  operation  and  to  suppurative  processes  in 
wounds,  usually  of  only  moderate  severity. 

The  Bacillus  pyocyaneus  is  the  cause  of  blue  and  green  pus.  It  is  rarely 
found  alone  in  infected  wound-,  and  rarely  has  a  special  pathological  signifi- 
cance. I  have  commonly  seen  it  as  a  secondary  invader  of  chronically  .sup- 
purating wounds.  It  imparts  to  the  dressings  a  peculiar  greenish  color  and  a 
musty  odor.  It  is  often  found  associated  with  Bacillus  tuberculosis  in 
tuberculous  lesions. 

The  Bacillus  coli  communis  is  found  in  abscesses  and  other  inflammatory 
processes  in  the  neighborhood  of  or  originating  in  the  alimentary  canal — nota- 


68         DISEASES    CAUSED   BY   THE   PUS-PRODUCING   BACTERIA 

bly  in  ischiorectal  abscess  and  in  some  forms  of  appendicitis  and  peritonitis. 
It  may,  however,  occur  in  abscesses  in  other  situations. 

The  Micrococcus  tetragenus  is  often  present  in  the  suppurative  portion  of 
the  lesion  of  tuberculosis  of  the  lungs,  and  may  be  found  also  in  abscesses  con- 
nected with  the  mouth  and  throat. 

The  Gonococcus. — In  addition  to  the  ordinary  lesions  of  acute  gonorrhea 
the  gonococcus  is  the  cause  of  a  great  variety  of  inflammatory  lesions,  acute, 
subacute,  and  chronic  in  character,  not  only  in  the  geni to-urinary  tract  and 
other  mucous  membranes,  but  also  in  many  other  situations.  In  many  of 
these  the  gonococcus  may  be  found  alone,  in  others  associated  with  other  organ- 
isms— notably  the  colon  bacillus  and  the  pyogenic  cocci.  Among  the  former 
group  may  be  mentioned  peritonitis,  gonorrheal  synovitis,  tenosynovitis,  and 
bursitis,  endocarditis,  pleuritis,  meningitis;  among  the  latter  some  gonorrheal 
cystites  and  acute  suppurative  lesions  of  the  kidney  associated  with  gonorrhea. 
The  gonococcus  is,  moreover,  capable  of  producing  a  general  septicemia.  The 
character  of  the  inflammatory  exudate  in  gonorrheal  infections  of  mucous  mem- 
brane is  purulent.  In  serous  membranes  it  may,  as  is  the  case  with  the  ordi- 
nary pyogenic  cocci,  cause  serous,  fibrinous,  sero-purulent  or  purulent  exuda- 
tion. In  synovial  membranes  sero-fibrinous  exudates  containing  a  moderate 
number  of  white  cells  are  the  rule,  though  purulent  exudates  may  occur.  The 
gonococcus  is  capable  of  causing  suppuration  in  connective  tissues,  muscles, 
etc.,  in  the  same  sense  as  the  pyogenic  cocci  in  rare  cases.  I  know  of  a  case, 
a  young  man  on  the  house  staff  of  one  of  the  hospitals  of  this  city,  who  devel- 
oped a  tedious  paronychia  on  two  fingers  successively.  The  gonococcus  was 
identified  in  the  purulent  discharge  from  each.  Powers  described  a  case  of 
gonococcus  infection  of  the  entire  upper  extremity. 

OCCURRENCE    OF    PYOGENIC    GERMS    IN    VARIOUS    TISSUES 

Occurrence  of  Pyogenic  Germs  upon  the  Skin. — The  pyogenic  bacteria  may 
occur  in  the  human  body  in  various  situations  without  necessarily  giving  rise 
to  pathological  changes.  While  the  general  surface  of  the  integument  does 
not  afford  a  favorable  soil  for  the  growth  of  bacteria  under  normal  conditions, 
yet  a  great  variety  of  such  organisms  have  been  demonstrated  upon  the  skin 
of  healthy  individuals  as  casual  inhabitants.  The  Staphylococcus  epidermidis 
albus  of  Welch  appears,  as  already  stated,  to  exist  normally  in  the  hair  folli- 
cles and  sweat  and  sebaceous  glands.  Certain  situations  are  more  favorable 
for  the  growth  of  micro-organisms  than  others — namely,  where  the  surface 
is  moist  and  two  layers  of  skin  are  in  contact;  the  axilla  and  groins,  the  skin 
between  the  toes,  the  scrotum,  the  vulva,  the  canal  of  the  external  ear,  the  folds 
of  skin  beneath  the  nails,  are  very  commonly  the  temporary  home,  at  least,  of 
many  kinds  of  organisms.  The  fingers  of  surgeons,  nurses,  and  others  who 
come  much  into  contact  with  pathological  material  are  quite  commonly  found 
to   contain  pyogenic   cocci   in  large  numbers.      Indeed,   the   impossibility  of 


OCCURRENCE    OF    PYOGENIC    GERMS    IN    VARIOUS    TISSUES 

entirely  removing  such  germs  bae  led  to  the  mosl  important  advance  in  the 
technic  of  aseptic  surgery  in  recenl  years-  namely,  the  regular  use,  by  the 
<'iii ire  personnel  of  Burgical  operating  rooms,  of  sterilized  rubber  glo 

From  the  general  integumenl  the  pyogenic  cocci  can,  with  the  exception 
of  Staphylococcus  epidermidis  albus,  be  usually  removed  by  suitable  mechan- 
ical mimI  antiseptic  measures,  although  where  the  skin  is  thick  and  horny  the 
cocci  in  the  deeper  layers  of  the  epidermis  are  nol  always  dead,  as  Bhown  by 
cultures  made  from  deep  scrapings  from  such  surfaces,  even  after  prolonged 
and  careful  efforts  a1  disinfection.  The  streptococcus  is  less  often  found  upon 
the  skin  than  the  different  varieties  of  staphylococci,  excepl  in  cases  of  per- 
sons with  infected  wounds  it  who  come  into  contact  with  sources  of  infection. 
The  colon  bacillus  is  often  found  upon  the  skin  near  the  anus;  and  the  bacillus 
of  tetanus  and  of  malignant  edema  may  be  presenl  upon  the  -kin  of  the  feet 
of  those  who  walk  barefooted  upon  garden  .-"il  or  who  have  hole-  in  their  shoes. 
Tlic  significance  of  the  smegma  bacillus  in  relation  to  errors  in  the  diagnosis 
of  tuberculosis  of  the  genito-urinary  tract  will  lie  spoken  of  in  another  place. 

Pyogenic  Bacteria  on  Mucous  Membranes. — The  conjunctiva,  although  ex- 
posed  in  many  ways  to  the  entrance  of  bacteria  from  many  sources,  usually 
gets  rid  of  bacteria  quite  rapidly.  The  lachrymal  secretion  kills  some  varieties, 
but  most  of  them  find  their  way  in  a  surprisingly  short  time  through  the 
lachrymal  duct  into  the  nose.  Thus,  although  rarely  sterile,  cultures  from 
the  conjunctival  sac  in  health  ordinarily  furnish  few  or  no  pathogenic  forms. 
The  mouth  tiinl  fhroat  are  continually  exposed  to  the  entrance  of  bacteria  of  all 
sorts.  A  large  part  of  these  are  got  rid  of  rapidly,  but  the  mouth  is  con- 
stantly the  home  of  a  great  variety  of  forms;  some  of  them  pathogenic,  souk* 
of  them  not.  Among  the  pathogenic  forms  quite  commonly  found  in  the  mouth 
and  throat  are,  according  to  Welch,  Micrococcus  lanceolatus,  Streptococcus 
pyogenes,  Staphylococcus  aureus  and  albus,  Micrococcus  tetragenus,  Bacillus 
pneumonia?  of  Friedliindcr,  Bacillus  crassus  sputigenus  of  Kreibohm,  Bacillus 
coli  communis.  Streptococcus  pyogenes  appears  very  commonly  in  the  healthy 
mouth.  In  conditions  of  inflammation  of  the  mouth  and  air  passages  their 
number  is  usually  notably  increased.  They  may  be  of  slight  or  great  virulence, 
and  are  always  a  cause  of  anxiety  to  the  surgeon  in  operations  upon  the  mouth 
and  air  passages,  because  under  such  circumstances  they  may  and  often  do 
produce  local  and  general  infections  and  pneumonias  of  a  grave  type.  The 
Staphylococcus  pyogenes  aureus  appears  less  commonly  in  the  mouth  than  does 
Streptococcus  pyogenes. 

The  tonsils,  owing  to  their  situation,  their  peculiar  physical  conformation, 
and  the  character  of  the  tissue  composing  them,  are  withoul  doubt  a  frequent 
avenue  of  entrance  for  many  varieties  of  pathogenic  germs  into  the  organism. 
They  are  not.  only  the  seal  of  numerous  inflammatory  processes  which  occur 
as  more  or  less  localized  infections  of  tin'  tonsils  themselves,  or  include  also  the 
neighboring  tissues,  but  inflammations  of  the  tonsils  and  pharynx  are  exo 
ingly  common  as  a  part  of  the  symptom-complex  of  a  greal  variety  of  in  fee 


70         DISEASES    CAUSED   BY   THE   PUS-PRODUCING   BACTERIA 

tious  diseases — notably,  the  acute  exanthemata.  Moreover,  it  has  been  observed 
that  attacks  of  acute  articular  rheumatism  and  acute  osteomyelitis  of  the  long- 
bones  are  preceded  by  a  tonsillitis  in  a  considerable  proportion  of  cases.  The 
tubercle  bacillus  has  often  been  found  in  crypts  of  the  tonsil.  The  nasal 
mucous  membrane  acting,  as  it  does,  as  a  filter  for  the  inspired  air,  may  con- 
tain in  health  many  varieties  of  bacteria.  The  pyogenic  cocci  are  less  com- 
monly present  in  large  numbers  than  in  the  mouth.  The  deeper  air  passages 
in  health  contain  comparatively  few  bacteria,  the  action  of  the  ciliated  epi- 
thelium being  to  force  them  out,  and  the  filtering  action  of  the  upper  air 
passages  diminishing  greatly  the  number  entering  with  the  inspired  air. 

The  Bacteria  of  the  Stomach  and  Intestine  and  Biliary  Passages. — Enormous 
numbers  of  bacteria  are  swallowed  with  the  food.  Theoretically,  many  of 
these  are  killed  in  the  stomach  by  the  gastric  juice ;  practically,  many  remain 
alive.  In  the  small  intestine  the  pyogenic  cocci  are  regularly  found  as  well 
as  many  other  varieties,  including  the  colon  bacillus,  in  some  cases  Bacillus 
aerogenes  capsulatus.  In  the  large  intestine  the  variety  found  is  less.  The 
colon  bacillus  is  always  present,  Many  of  the  varieties  requiring  air  find  an 
unfavorable  soil,  and  a  considerable  proportion  are  discharged  dead  with  the 
feces.  Tetanus  spores  may  develop  into  bacilli  in  the  intestine,  and  tetanus 
bacilli  as  well  as  the  bacilli  of  malignant  edema  are  often  present  in  the  intes- 
tines of  herbivorous  animals  (Welch). 

The  Biliary  Passages. — In  health  the  bile  may  be  sterile,  or,  on  the  other 
hand,  may  contain  pyogenic  bacteria.  In  inflammatory  conditions  of  the  bil- 
iary passages,  and  always  in  the  presence  of  biliary  calculi,  the  pyogenic  bac- 
teria are  found  in  the  gall-bladder  in  greater  or  less  numbers. 

Bacillus  typhosus  may  long  remain  alive  and  virulent  in  the  gall-bladder, 
and  consequently  in  the  feces,  after  convalescence  from  typhoid  fever.  For 
example,  there  is  at  present  confined  by  the  board  of  health  on  one  of  the 
islands  in  the  East  River  a  woman,  a  cook,  who  has  carried  typhoid  infection 
into  a  number  of  families  with  whom  she  has  lived  during  the  past  three  or 
four  years.  Her  feces  have  contained  virulent  typhoid  germs  during  all  this 
period.  Under  medication  and  a  restricted  diet  the  bacilli  diminish  in  num- 
ber or  disappear.  When  an  ordinary  diet  is  resumed  they  become  abundant. 
This  is  not  a  unique  case.  It  is  probable  that  many  individuals  remain  in  this 
way  disease  carriers  for  long  periods.  It  is  known  to  be  true  in  numerous 
instances  of  diphtheria. 

The  Male  Urethra. — Normally,  the  male  urethra  contains  bacteria  in  its 
anterior  portion  in  varying  numbers.  The  deeper  the  portion  from  which 
the  culture  is  made,  the  more  likely  it  is  to  be  sterile.  Bacteria  probably  do 
not  exist  in  the  healthy  bladder.  The  bacteria  found  in  the  urethra  are  the 
smegma  bacillus,  the  Bacillus  coli  commune,  various  saprophytic  forms,  and 
several  forms  of  diplococci  more  or  less  resembling  the  gonococcus,  the  differ- 
entiation of  which  will  be  spoken  of  under  the  diagnosis  of  gonorrhea.  True 
pyogenic  cocci  may  also  be  found  in  the  healthy  male  urethra  occasionally. 


SOURCES    OF    BACTERIA    IN    PYOGENIC    INFECTIONS  71 

The  Female  Urethra. — The  pyogenic  cocci  may  !><•  present  in  the  female 
urethra  in  healthy  individuals.  It  is  probable  thai  in  healthy  virgins  the 
accidental  presence  of  such  germs  is  less  common  than  in  women  who  have 
borne  children  and  whose  vagina  are  more  apl  to  contain  bacteria  of  various 
Borts,  accompanied  often  by  catarrhal  inflammation  of  the  cervical  endometrium. 
The  vagina  contains  bacteria  in  considerable  variety  in  health.  Doederlein 
in  1892  described  a  group  of  bacilli  which  grew  upon  an  acid  medium.  These 
organisms  were  nonpathogenic,  and  were  regarded  by  him  as  the  mal  in- 
habitants of  this  canal.  As  to  the  frequency  of  the  occurrence  of  the  pus- 
producing  bacteria  in  the  vaginas  of  healthy  pregnanl  and  nonpregnant  women 
various  observers  differ,  but  the  probability  seems  to  be  thai  their  occurrence 
is  rather  exceptional.  The  acid  secretion  of  the  vagina  seems  to  have  a  power- 
ful destructive  action  on  many  forms  of  pathogenic  bacteria,  such  that  they 
arc  rather  rapidly  destroyed  after  accidental  introduction.  The  normal  cervix 
and  endometrium  are  free  from  bacteria,  owing,  it  is  believed,  partly  to  the 
mechanical  obstruction  to  their  entrance  and  partly  to  the  bactericidal  quality 
<>(  the  secretions,  which  are  here  alkaline  in  reaction. 

The  milk  of  the  breast  contains  normally,  according  to  Welch,  only  the 
Staphylococcus  epidermidis  albus  derived  from  the  lacteal  ducts  near  their 
orifices.  Other  pyogenic  organisms  may  be  present  in  the  ducts,  but  they  are 
less  common. 

SOURCES    OF    BACTERIA    IN    PYOGENIC    INFECTIONS 

In  pyogenic  infections  the  bacteria  may  be  derived  from  various  sources. 
We  may  assume  that  the  healthy  internal  tissues  of  the  body  are  free  from 
bacteria,  or  at  least  that  their  occurrence  is  very  rare.  The  bacteria  upon  the 
skin  may  he  sources  of  infection  in  accidental  wounds  and  in  surgical  operations 
where  the  skin  has  been  imperfectly  cleaned,  and  bacteria  in  the  hair  follicles 
may,  as  the  result  of  slight  traumatisms,  such  as  continued  friction,  give  rise 
to  local  or  general  infections — notably,  in  persons  who  are  badly  nourished. 
Such  infectious  occur  during  convalescence  from  acute  diseases,  and  notably  in 
persons  suffering  from  diabetes  and  from  chronic  nephritis.  Bu1  in  by  far 
the  largest  proportion  of  cases  such  infections  arc  caused  by  bacteria  intro- 
duced from  without  ;  by  infected  materials  introduced  into  the  wound  at  the 
time  of  the  accident  or  during  the  imperfectly  conducted  surgical  operation. 

Another  group  of  Infections  occurs  without  mechanical  injury.  In  these 
the  resistance  of  the  tissues  to  the  pus-producing  organisms  has  been  lowered 
by  some  antecedent  infection  or  depressing  condition.  In  these  cases  the 
secondary  pus  infection  often  takes  place  through  the  tonsils,  mouth,  throat, 
and  alimentary  canal.  Thus  following  the  exanthemata  diphtheria,  typhoid 
fever,  and  other  infectious  diseases — septic  processes  occur  as  secondary  infec- 
tions from  the  pyogenic  bacteria  present  in  the  mucous  membranes.  The  de- 
pressed states  of  vitality  induced  by  the  antecedent  disease  has  permitted  the 


72         DISEASES    CAUSED    BY    THE   PUS-PRODUCING   BACTERIA 

pyogenic  cocci  present  to  invade  and  multiply  in  the  tissues.  At  the  present 
time  surgeons  are  not  inclined  to  lay  much  stress  upon  the  danger  of  wound 
infection  from  the  air.  It  is  quite  true  that  the  air  of  hospital  operating  rooms 
may  often  he  demonstrated  to  contain  pyogenic  bacteria  in  varying  number; 
but  it  is  not  generally  believed  that  wound  infection  from  this  source  is  com- 
mon, or  at  least  that  the  number  of  bacteria  falling  into  a  wound  from  the  air 
is  ordinarily  great  enough  to  cause  infection. 

TOXIC    AND    OTHER    EFFECTS    OF    PYOGENIC    ORGANISMS 

The  action  of  the  pus-producing  organisms  upon  the  human  body  is  of  a 
somewhat  complex  character.  Certain  local  changes  are  produced  in  the  tissues 
in  the  area  where  the  bacteria  are  growing- — inflammation,  suppuration,  necro- 
sis ;  and  certain  substances  are  elaborated,  due  to  chemical  changes  in  the  tissue 
fluids,  or  produced  by  the  bacteria  themselves  in  any  medium  which  affords 
them  nourishment  (toxins).  The  absorption  into  the  lymph  current  or  circu- 
lating blood  of  these  toxic  substances  produces  general  disturbances  of  nutri- 
tion as  well  as  effects-  upon  the  nervous  mechanism  of  the  central  nervous  sys- 
tem. These  disturbances  are  commonly  characterized  by  an  elevation  of  the 
body  temperature,  by  prostration,  by  an  increased  pulse  rate,  and  other  symp- 
toms which  will  be  spoken  of  later.  These  local  and  general  disturbances  bear 
no  very  constant  relation  one  to  the  other.  A  considerable  local  reaction  may 
be  present  without  profound  intoxication,  and  severe  and  even  fatal  blood 
poisoning  may  occur  with  but  trifling  signs  of  local  inflammation.  In  other 
cases  the  two  sets  of  phenomena  advance  pari  passu. 

As  we  have  already  seen,  the  bacteria  may  enter  an  open  wound.  Such 
wounds  as  are  contused,  or  which  contain  masses  of  coagulated  or  fluid  blood 
or  portions  of  tissue  strangulated  by  sutures  and  by  ligatures,  and  wounds  the 
walls  of  which  are  in  a  state  of  tension  from  any  cause,  are  more  favorable 
sites  for  the  successful  growth  of  bacteria  than  are  clean-cut  wounds  in  which 
these  conditions  favoring  infection  are  absent.  Further,  the  dose  of  bacteria 
and  their  toxins  received  has  an  important  bearing  upon  the  severity  of  the 
infection.  A  moderate  number  of  bacteria  of  a  certain  degree  of  virulence 
may  cause  no  interference  with  wound  healing,  whereas  a  larger  number  may 
cause  serious  disturbance.  The  resistance  of  the  tissues  of  the  individual  also 
plays  an  important  role.  A  person  in  robust  health  may  get  rid  of  a  number 
of  virulent  germs  which  in  an  individual  debilitated  from  disease,  from  ane- 
mia, from  imperfect  blood  circulation,  or  other  cause,  might  lead  to  serious  or 
fatal  infection.  It  is  nevertheless  true  that  there  are  germs  so  virulent  that 
a  few  would  be  sufficient  to  infect  the  strongest  individual.  Personal  idiosyn- 
crasy plays  also  a  not  unimportant  role.  There  are  individuals  who  appear 
to  be  much  less  susceptible  to  pyogenic  infections  than  others  apparently  quite 
as  robust  and  vigorous,  and  the  susceptibility  of  the  same  individual  no  doubt 
varies  from  time  to  time  without  apparent  cause. 


TOXIC    AND   OTHER    EFFEQTS    OF    PYOGENH     ORGANI8M8        73 

Local. —  The  local  disturbances  at  tin*  -im  of  an  infection  with  pyogenic 
microbes  are  due  in  part  i<>  the  activities  of  the  bacteria  themselves  and  in 
pari  to  the  effort  on  the  part  of  the  tissues  to  destroy  them  and  to  limit  their 
sphere  of  activity.  The  pyogenic  cocci  produce  proteid  substances  which  destrov 
the  vitality  of  the  tissue  cells,  causing  first  death  and  later,  by  a  peptonizing 
action.  Boftening  of  the  dead  tissue.  The  presence  of  this  bacterial  proteid 
causes  what  is  known  as  a  chemotactic  effect;  namely,  the  white  blood  cells 
are  attracted  in  larger  numbers  t<»  the  site  <>f  infection,  and  they  soon  form  a 
living  wall  around  the  infected  tissues,  tending  thus  to  limit  mechanically  the 
spread  of  the  bacteria.  The  leucocytes,  moreover,  include  within  themselves 
numbers  of  bacteria,  and  destroy  them  apparently  by  a  process  of  digestion. 
The  white  cells,  also,  are  believed  to  furnish  a  bactericidal  substance  known 
as  germicidal  proteid.  If,  however,  the  process  i-  to  end  in  suppuration,  many 
of  the  leucocytes  fail  to  leave  the  seat  of  inflammation  alive,  and  remain  with 
their  contained  bacteria  as  one  of  the  ingredients  of  pus. 

'I'he  tissue  thuds  of  the  body  and  the  blood  sernm  also  exercise  an  inhibitory 
and  destructive  effect  upon  the  bacteria  by  virtue  of  a  substance  known  as 
nuclein.  In  addition  to  crowded  leucocytes,  an  exudate  of  fibrin  is  thrown 
out  by  the  blood-vessels  around  the  infected  focus,  so  that  in  many  instances 
the  tissues  succeed  in  limiting  the  bacterial  growth  to  a  circumscribed  area. 
The  tissues  may  be  so  successful  that  no  portion  of  tissue  undergoes  purulent 
softening,  and  the  bacteria  are  destroyed  partly  in  situ,  partly  by  leucocytes 
which  re-enter  the  circulation,  partly  by  the  tissue  cells  of  distant  organs  in 
which  the  bacteria  may  he  transmitted  by  the  blood  or  lymph  current,  and 
partly,  also,  it  is  believed,  by  the  endothelial  cells  lining  the  capillary  blood- 
vessels. Living  bacteria  may  also  he  eliminated  through  the  kidneys,  through 
the  mucous  membrane  of  the  alimentary  canal,  through  the  sweat  glands,  ami 
through  the  respiratory  tract.  The  pain,  heat,  redness,  and  swelling  charac- 
teristic of  local  inflammation  subside,  and  the  process  ends  in  resolution,  so 
called. 

Such  a  result  is  often  seen  in  slightly  infected  wounds  after  operation;  at 
the  end  of  two  or  three  days  after  the  operation  slight  redness  of  the  >kin  is 
observed  along  the  skin  edges  of  the  wound,  a  little  swelling  occurs,  and  the 
wound  v<\<j;vs  are  a  little  tender  and  a  little  painful.  Such  swelling  and  redness 
will  be  noted  especially  at  the  points  under  slight  tension  from  sutures.  A 
few  drops  of  sero-sanguinoleiit  discharge  may  escape  upon  removing  a  suture 
or  one  of  the  folded  strands  of  rubber  tissue  commonly  introduced  into  the 
ends  of  skin  incisions  for  purposes  of  drainage.  But  the  process  will  stop  at 
this  point,  no  pus  will  he  formed,  the  symptoms  and  signs  of  inflammation 
will  gradually  subside,  and  more  or  Less  complete  primary  union  will  be 
obtained  in  the  wound. 

If  the  grade  of  infection  is  more  severe,  the  process  will  end  in  suppura- 
tion. Suppuration  may  hi-  localized  or  diffuse.  A  localized  suppurative  area 
is  known  as  an   abscess.      Diffuse  suppuration  i~  often   attended   by  extensive 


74        DISEASES    CAUSED   BY   THE   PUS-PEODUCING   BACTEEIA 

necrosis  of  tissue,  and  is  sometimes  spoken  of  as  phlegmonous  inflammation. 
Circumscribed  suppuration  is  most  often  caused  by  Staphylococcus  pyogenes 
aureus;  diffuse  suppuration  by  Streptococcus  pyogenes. 

Furuncle. — The  diagnosis  of  abscess,  if  situated  near  the  surface,  is  easy ; 
if  in  an  internal  organ,  it  may  be  extremely  difficult.  Among  the  commonest 
forms  of  superficial  abscess  is  a  boil  or  furuncle.  Furuncle  is  an  acute  puru- 
lent inflammation  of  the  skin  around  a  hair  follicle  or  cutaneous  gland ;  it  is 
caused  most  often  by  Staphylococcus  pyogenes  aureus.  Depressed  states  of 
health,  diabetes,  and  convalescence  from  acute  diseases  predispose  to  the  occur- 
rence of  furuncle.  The  boils  may  be  solitary,  or  several  may  occur  in  the  same 
region  or  scattered  over  various  parts  of  the  body  (furunculosis).  It  is  prob- 
able that  infection  is  often  carried  by  the  fingers  to  other  parts,  causing  new 
foci  of  infection.  Continued  mechanical  irritation  is  often  the  exciting  cause 
of  furuncle,  as,  for  example,  horseback  riding,  rowing,  the  friction  of  a  collar 
button  uiDon  the  back  of  the  neck. 

The  favorite  sites  of  furuncle  are,  as  suggested,  the  nates,  the  back  of  the 
neck,  the  face  and  back,  and  sometimes  other  regions.  A  furuncle  begins  as 
a  minute  red,  tender  point  surrounding  the  orifice  of  a  cutaneous  gland  or 
hair  follicle.  The  subjective  sensation  of  itching  and  tenderness  are  early 
present.  The  red  area  increases  in  size,  and  in  the  course  of  two  or  more 
days  may  become  as  large  as  a  silver  dime  or  twenty-five-cent  piece.  It  is 
elevated  above  the  level  of  the  surrounding  skin,  conical  in  shape,  bright  red 
in  color.  It  may  be  quite  painful,  and  is  very  sensitive  on  pressure.  At  the 
center  of  the  swelling  there  soon  appears  a  round,  white  or  yellowish  spot;  a 
thin  pellicle  of  skin  covering  this  area  permits  the  yellowish  color  of  the  under- 
lying pus  to  shimmer  through.  If  the  pellicle  is  ruptured,  the  exuding  drop 
of  pus  dries  into  a  crust. 

If  the  boil  is  incised  at  this  time,  a  small  cavity  from  one  quarter  to  one 
half  inch  deep  will  be  opened,  containing  a  few  drops  of  pus  and  a  central 
necrotic  mass  representing  the  original  focus  of  infection  and  surrounded  by 
more  or  less  necrotic  tissue.  If  the  furuncle  is  allowed  to  rupture,  a  few  drops 
of  pus  may  be' squeezed  out,  followed  by  a  minute  slough — the  so-called  core 
of  the  boil.  During  the  height  of  the  process,  and  before  incision  or  rupture, 
moderate  fever  and  leucocytosis  may  be  present.  Healing  follows  by  granula- 
tion, with  gradual  subsidence  of  the  inflammation.  In  enfeebled  individuals 
a  boil  or  congeries  of  boils  may  form  with  the  production  of  a  carbuncle. 

Carbuncle. — Carbuncle  is  a  suppurative  and  necrotic  inflammation  of  the 
skin  and  subcutaneous  tissues.  Staphylococcus  pyogenes  aureus  is  the  organ- 
ism most  frequently  concerned  in  the  process.  Carbuncle  is  rare  in  childhood, 
and  is  most  frequent  after  the  fortieth  year  of  life.  The  most  common  sites 
are  the  back  of  the  neck,  the  back,  and  the  lip.  The  disease  commonly  attacks 
persons  not  in  robust  health,  those  convalescing  from  acute  diseases,  diabetics, 
and  chronic  alcoholics,  but  healthy  adults  may  also  suffer.  In  these  the  con- 
stitutional symptoms  may  be  slight,  but  in  the  debilitated  and  diabetic,  grave 


Toxic    AXT)    oTlll.l;    I  II  l.<  "IS    OF    PYOGENIC    ORGANISMS        75 


constitutional  depression  accompanies  the  disease,  ;in<l  the  prognosis  is  most 
serious.  The  disease  m.i\  begin  as  a  simple  furuncle,  or  as  a  number  of  furun- 
cles in  juxtaposition;  the  process  is  aol  limited  to  the  -kin,  Inn  extends  laterally 
and  into  the  subcutaneous  tissues,  following  the  columns  of  fal  which  lie  be- 
tween the  connective-tissue  bundles.  In  size,  carbuncle  varies  from  thai  of 
a  silver  half  dollar  to  thai  of  a  dinner  plate.  It  is  usually  solitary.  The 
inflamed  area  is  deeply  red,  sometimes  purple,  elevated  above  the  surrounding 
skin,  and  ova]  or  rounded  in  shape.  The  swelling  is  hard,  tender,  painful,  and 
firmly  adherenl  to  the  deeper  structures.  After  a  few  days  uumerous  small 
openings  form  upon  the 
surface,  and  through  them 
;i  tliin  pus  exudes. 

I  f  nol  operated  upon,  a 
large  carbuncle  may  take 
ten  days  or  two  week-  to 
fully  develop.  Sloughing 
of  the  overlying  skin  finally 
(•reins,  sometimes  over  ;i 
large  area ;  the  skin  be- 
comes riddled  with  open- 
ings like  a  sieve,  and 
through  the  openings  thus 
funned  sloughing  masses  of 
connective  tissue  and  pus 
are  discharged.  Necrosis 
of  the  infected  t  issue  leads 
to  a  soft,  boggy  condition  of 
the  centra]  mass,  surround- 
ed by  a  dense,  hard  area  of 
infiltration.  When  carbun- 
cle involves  the  neck  and 
back,  the  sloughing  usually 
extends  to  the  fascia  cover- 
ing   the    muscles,    and    the 

extent  of  the  infection  of  the  deeper  tissues  is  often  greater  than  the  inflamed 
area  of  skin  would  indicate. 

The  constitutional  disturbance  attending  carbuncle  is  often  Bevere.  In  old 
and  feeble  persons,  and  in  the  diabetic,  the  constitutional  depression  is  extreme. 
In    ordinary    cases    there    will    lie    moderate    fever    of    a    remitlent    type,    and    a 

corresponding  rapidity  of  pulse-rate.  Leucocytosis  i>  present,  and  varies  ac- 
cording to  tlie  size  and  severity  « 4*  the  infection.  In  the  aged  and  diabetic, 
leucocytosis  may  be  wanting,  the  polynuclear  cells  will  show  a  relative  increase, 
fever  may  he  absent,  hut  the  pulse  will  l.e  rapid  and  feeble  and  the  weakness 
extreme;  anemia  is  often  pronounced.     Fatal  septicemia,  or  death  in  diabetic 


lie  It. — Carbuncle  of  the  Back.      (.New  York  Hospital.) 


76         DISEASES    CAUSED    BY    THE    PUS-PEODUCTXG   BACTEEIA 

coma,  are  not  uncommon.  Carbuncle  of  the  lip  is  dangerous,  and  even  fatal 
in  certain  cases  from  purulent  phlebitis  of  the  veins  communicating  with  the 
interior  of  the  skull,  resulting  in  sinus  thrombosis  and  pyemia  or  in  meningitis. 
Carbuncle  of  the  lip  may  end  in  this  manner  even  in  young  and  robust  indi- 
viduals  (see  Face). 

Phlegmonous  Inflammation. — By  phlegmonous  inflammation  we  un- 
derstand that  form  of  infection  with  pyogenic  microbes  which  is  attended 
rather  by  necrosis  and  sloughing  of  .the  tissues  than  by  the  mere  production 
of  pus.  Purulent  softening  and  suppuration  of  the  living  tissues  at  their 
junction  with  the  dead  parts  is  a  later  development  of  the  process  in  many 
instances :  in  others  the  purulent  and  necrotic  processes  advance  hand  in  hand. 
Clinically  we  may  distinguish  two  forms  of  phlegmonous  inflammation — the 
circumscribed  and  the  diffuse  or  spreading  phlegmon.  The  microbes  concerned 
in  the  diffuse  form  are  often  Streptococcus  pyogenes.  There  may  be  a  forma- 
tion of  gas  in  the  tissues,  and  putrid  decomposition  of  the  sloughs  due  to  the 
growth  of  saprophytes. 

Circumscribed  Phlegmons. — These  are  caused  sometimes  by  the  Staphylo- 
coccus pyogenes  aureus.  The  origin  of  the  inflammation  is  often  in  a  trifling 
wound  or  abrasion  of  the  skin,  in  a  needle  puncture,  a' blister,  an  inflamed 
bursa,  an  ulcer  of  the  leg;  sometimes  in  a  small  abscess,  such  as  abscess  of  the 
pulp  of  the  finger ;  sometimes  in  severe  injuries,  such  as  compound  fractures 
of  the  extremities  and  crushing  injuries.  Sometimes  the  bacteria  are  taken 
up  by  the  lymph  vessels,  and  make  a  successful  lodgment  in  the  communicating 
lymphatic  glands,  and  produce  phlegmonous  inflammation  in  their  vicinity 
(see  Lymphangitis).  The  tissues  involved  in  phlegmonous  inflammations  are 
the  skin,  the  subcutaneous  tissues,  the  tendon  sheaths,  the  fascia  and  the  fascial 
and  loose  connective  tissues  of  the  intermuscular  planes,  rarely  the  muscles  and 
periosteum  ;  sometimes  joints  are  invaded.  In  not  a  few  instances  of  the  severer 
forms  of  this  type  of  infection  septicemia  and  pyemia  are  fatal  complications. 
The  signs  and  symptoms  of  phlegmonous  inflammations  will  vary  according  to 
the  process  and  the  severity  of  the  infection. 

Constitutional  Symptoms. — The  constitutional  symptoms  are  ordinarily 
marked,  and  consist  often,  at  the  beginning,  of  chilly  sensations  or  a  distinct 
chill,  accompanied  by  a  rise  of  temperature  which  will  vary  according  to  the 
activity  and  extent  of  the  process.  The  temperature  may  rise  suddenly  to 
102c  or  104c,  or  in  severe  cases  to  106°  F.  The  pulse  will  increase  in  rapidity 
to  an  extent  commensurate  with  the  temperature,  or  in  the  most  rapidly  fatal 
cases  there  will  be  little  or  no  rise  of  temperature,  but  a  rapid,  compressible 
pulse  almost  from  the  first.  At  first  the  pulse  will  be  full  and  bounding ;  later, 
if  the  case  goes  badly,  more  and  more  rapid  and  feeble.  There  will  be  the 
ordinary  symptoms  of  septic  intoxication:  headache,  loss  of  appetite,  a  coated 
tongue,  and  prostration.  The  pain  will  depend  to  some  extent  upon  the  swell- 
ing and  tension,  and  upon  the  nerve  supply  of  the  part.  For  example,  a 
phlegmonous  process  confined  beneath  the  dense  fascia  of  the  palm  is  far  more 


TOXIC    AND    OTHER    KMKCTS    OF    PYOGENIC    ORGANISMS        77 

painful  than  a  similar  process  of  the  upper  arm  or  thigh.    The  local  -i^n-  also 

will  varv  in  some  extent,  depending  upon  whether  the  -kin  is  early  involved 

(if    lint. 

.1  Typical  Phlegmon  of  the  /'aim. — A  typical  phlegmon  of  the  palm  may 
lie  described  as  follows:  After  a  slight  infected  wound  or  abrasion  of  a  finger 
or  a  blister  upon  the  palm  of  the  hand,  the  patient  suddenly  begins  to  feel  ill; 
he  has  chilly  feelings  or  a  chill,  and  a  rise  of  temperature  to  L02  or  L03  F.; 
a  throbbing  pain  is  felt  iii  the  hand,  which  is  severe  enough  to  prevent  sleep. 
The  hand  becomes  swollen,  hut  redness  of  the  skin  i.-.  absenl  or  slight  The 
palm  becomes  very  tender  in  the  neighborhood  of  the  original  focus  of  infec- 
tion; as  tin'  davs  go  by,  the  whole  hand  becomes  swollen  and  edematous,  and 
the  swelling  extends  to  the  forearm.  The  skin  is  often  but  little  reddened  :  the 
throbbing  pain  increases  in  severity,  and  the  patient  feel-  ,-erioii-ly  ill.  The 
fever  is  of  the  remittent  type,  and  is  usually  higher  in  the  evening.  There  is 
complete  anorexia,  much  prostration,  and  sleeplessness.  Lencocvtosis  will  al- 
ways be  found,  of  moderate  or  considerable  degree.  The  large  polynuclear 
forms  will  be  relatively  increased  seventy  to  ninety-live  per  cent.  The  original 
focus  discharges  a  little  pus  on  pressure,  and  the  whole  palm  become-  exceed- 
ingly painful  and  tender. 

If  no  incisions  are  made  the  swelling-  extends  upward  to  the  elbow,  the 
whole  hand  becomes  greatly  swollen  and  edematous,  suggesting  the  bloated  ap- 
pearance of  the  abdomen  of  a  frog  (Frog  Felon).  If  at  the  end  of  a  week 
or  ten  days  incisions  arc  made  into  such  a  hand,  pus  will  be  found  confined 
beneath  the  palmar  fascia,  usually  in  large  quantity,  and  the  connective  tissue 
of  the  palm  and  the  tendon  sheaths  of  the  flexor  tendons  will  be  found  necrotic 
and  infiltrated  with  pus.  If  the  forearm  is  squeezed,  pus  will  be  seen  coming 
down  into  the  palm  from  beneath  the  annular  ligament  of  the  wrist,  and  an 
appropriate  incision  will  reveal  a  more  or  less  extensive  necrotic  and  purulent 
infiltration  of  the  deeper  connective  tissues  of  the  forearm,  of  the  intermus- 
cular planes,  and  of  the  tendon  sheaths  of  the  flexor  muscles. 

If  incision  is  still  longer  delayed,  the  skin  will  be  perforated  here  and 
there  in  the  hand  and  in  the  forearm,  and  from  the  openings  pus  and  necrotic 
masses  of  connective  tissue  and  tendon  sheaths,  and  later  tendons,  will  be 
extruded.  If  incisions  of  proper  character  are  made  early.  Ike  fane/ion  of 
most  or  all  of  the  tendons  of  the  hand  will  be  preserved]  if  not,  the  tendon 
sheaths  will  be  successively  and  insidiously  invaded  until  the  whole  hand  and 
the  palmar  aspect  of  the  forearm  become  riddled  with  purulent  and  necrotic 
tracts,  and  the  end  result  will  be  sometimes  septicemia  and  death,  sometime- 
a  crippled  hand,  and  sometimes  merely  a  contracted  and  useless  claw  upon 
which  the  subsequent  measures  of  massage,  passive  motion,  and  the  like  will 
be  of  small   benefit. 

Diffuse  or  Spreadin;/  Septic  Phlegmon  (Septic  Cellulitis). — A  mor< 
type  of  the  disease — a  spreading  septic  phlegmon — may  be  illustrated  by  a  case 
which  came  under  my  observation: 


78         DISEASES    CAUSED    BY    THE    PUS-PR ODUCENTG   BACTERIA 

A  large,  vigorous  laboring  man  entered  the  hospital  with  the  following  history : 
He  had  enjoyed  good  health  until  five  days  before  admission.  For  several  years 
he  had  a  small  bursa  over  the  olecranon  process  of  his  right  ulna ;  five  days  before 
he  had  scratched  or  abraded  the  skin  over  this  bursa;  the  same  night  he  had  a 
chill  followed  by  fever  and  sweating  and  his  elbow  had  become  painful  and  a  little 
swollen.  His  general  condition  had  continued  to  grow  worse;  the  swelling  of  his 
elbow  had  extended  up  and  down  his  arm:  and  on  the  fifth  day  he  was  brought 
to  the  hospital  in  the  ambulance  very  ill  indeed.  Upon  admission  his  temperature 
was  105°  F. ;  pulse  1*20;  his  face  was  flushed;  his  tongue  dry  and  coated;  he  com- 
plained of  feeling  much  prostrated  and  had  a  great  deal  of  pain  in  his  right  arm. 
Upon  examining  his  arm  it  was  noted  that  the  limb  was  swollen  from  the  wrist  to 
the  shoulder  to  nearly  twice  its  normal  size.  The  skin  of  the  arm  and  forearm  was 
bright  red  in  color  and  edematous  (cellulitis)  ;  the  redness  extended  from  the  wrist 
to  the  shoulder-joint.  Over  the  point  of  the  elbow  was  a  small  perforation  in 
the  skin  from  which  thin  pus  exuded  on  pressure.  Cultures  from  this  pus  gave 
a  pure  culture  of  Streptococcus  pyogenes — leucocyte  count  3 5.000,  eighty-five  per 
cent  polynuclears. 

Under  ether,  an  incision  was  made  along  the  dorsum  of  the  limb  from  the  shoul- 
der to  the  wrist.  The  subcutaneous  tissues  of  the  dorsum  of  the  limb  were  found 
everywhere  necrotic  and  infiltrated  with  a  thin  purulent  fluid,  and  were  dissected 
up  a  considerable  distance  on  either  side  of  the  incision.  The  limb  was  dressed 
in  a  suitable  manner  and  suspended  vertically  by  a  splint  and  pulley.  After  forty- 
eight  hours  his  fever,  which  had  remained  high,  began  to  subside.  The  leuco- 
cytosis.  which  had  been  35,000  on  admission,  fell  to  12,000.  The  relative  percentage 
of  large  polynuclears  underwent  a  marked  diminution.  At  no  time  did  cultures 
from  the  blood  give  positive  evidence  of  live  bacteria  in  the  circulation.  After  a 
long  convalescence  he  recovered  with  a  useful  limb. 

Mixed  Infection,  with  Streptococci  and  Saprophytic  Bacteria  (Proteus). — The 
most  severe  type  of  phlegmonous  inflammation  combined  with  infection  with 
saprophytic  bacteria  is  well  illustrated  by  the  following  case : 

A  young  man  was  accidentally  shot  in  the  forearm  by  the  discharge  of  a  shot- 
gun; the  charge  produced  a  ragged  hole  in  the  limb  just  below  the  elbow,  tearing 
the  skin,  muscles,  and  bones  in  a  destructive  manner.  He  was  brought  to  the  hos- 
pital three  days  later.  Upon  admission  he  was  delirious;  Ms  pulse  was  140;  his 
temperature  103.6°  F. ;  his  face  was  pale  and  his  body  was  bathed  in  a  clammy 
sweat.  Upon  examining  his  arm  the  wound  was  found  to  be  a  ragged  hole  through 
the  limb  about  two  inches  in  diameter;  the  surface  of  the  wound  was  necrotic 
and  gave  out  a  putrid  odor.  The  entire  limb  as  far  as  the  clavicle  was  greatly 
swollen  and  of  brawny  hardness.  The  surface  of  the  upper  arm  was  of  a  deep, 
dark-red  color  and  covered  with  blebs  containing  a  blood-stained  serum ;  upon 
palpation  the  subcutaneous  tissues  crepitated,  showing  the  presence  of  gas  beneath 
the  skin. 

Incision  into  the  limb  showed  a  necrotic  condition  of  the  subcutaneous  tissues, 
which  resembled  bacon  in  appearance.  Amputation  was  done  at  the  highest  possible 
point  at  once,  but  the  young  man  never  regained  consciousness  and  died  a  few 
hours  later.     Cultures  showed  the  presence  of  Streptococcus  pyogenes  and  of  sapro- 


PHYSICAL   SIGNS    AND    SYMPTOMS    OF    ACUTE    ABS<  l  3fi         79 

phytic  bacteria.     No  leucocyte  count   was  made.     Death  was  due  to  Budden  and 
profound  septicemia  and  Bapremia.     (See  Diagnosis  of  those  diseases.) 


THE  DIAGNOSIS  OF  LOCALIZED  FOCI  OF  SUPPURATION   (ABSCESS) 

Circumscribed  purulenl  foci  or  abscesses  may  occur  as  the  resull  of  a  great 
variety  of  conditions,  traumatic  or  other,  complicated  by  infection  with  pyogenic 
organisms.  They  may  occur  in  the  mosl  varied  regions  of  the  body,  and  the 
diagnosis  of  many  varieties  will  be  spoken  of  under  the  head  of  Regional 
Surgery.  Favorite  sites  for  abscess  arc  the  -kin  and  subcutaneous  tissues,  the 
lymphatic  glands,  the  loose  connective  tissue  of  the  neck,  of  the  ischiorectal 
fossn,  the  periosteum,  the  kidney  and  perirenal  tissues,  the  liver,  and  the 
pelvic  viscera  of  the  female.  Circumscribed  purulent  collections  also  occur 
in  many  other  situations — in  the  bones,  the  joints,  the  pleural  cavity,  the  peri- 
toneum, and  elsewhere — hut  these  purulent  accumulations  generally  receive 
special  name-,  as,  for  example,  circumscribed  osteomyelitis,  purulent  arthritis, 
empyema,  localized  purulent  peritonitis,  etc. 

PHYSICAL    SIGNS    AND    SYMPTOMS    OF    ACUTE    ABSCESS 

The  signs  and  symptoms  of  acute  abscess,  wherever  situated,  are  partly 
due  to  the  abscess  itself  and  partly  due  to  its  proximity  to  other  organs.  The 
9igns  and  symptoms  of  acute  purulent  inflammation  are  usually  present — 
namely,  pain,  heat,  redness,  and  swelling-,  and,  after  purulent  softening  has 
taken  place,  fluctuation,  if  the  abscess  be  so  situated  as  to  enable  this  sign  to 
be  appreciated.  Constitutional  disturbance  is  also  present,  and  i-  discussed 
at  length  under  the  head  of  Septic  Intoxication. 

Pain. — As  already  noted,  the  pain  of  abscess  varies  greatly  with  the  situa- 
tion. When  situated  in  loose  connective  tissues  pain  may  be  slight,  even 
though  the  abscess  be  extensive — for  example,  in  the  subcutaneous  connective 
tissue  of  the  thigh  or  arm.  On  the  other  hand,  the  pain  due  to  the  tension 
of  the  inflammatory  exudate,  when  situated  in  unyielding  tissues  or  in  the 
neighborhood  of  sensitive  nerve  trunks,  may  be  excruciating,  even  though  the 
focus  is  small — for  example,  purulent  collections  in  the  medulla  of  the  bones, 
in  the  wall  of  the  canal  of  the  external  ear,  beneath  the  dense  connective  tissue 
of  the  pulp  of  a  finger  or  toe,  or  in  the  tongue,  are  usually  exceedingly  painful. 

The  pain  of  abscess  goes  on  increasing  until  the  tension  of  the  pus  i-  re- 
lieved by  incision,  or  by  necrosis  and  perforation  of  the  surrounding  tissues 
and  the  escape  of  the  pus.  Such  perforation  may  take  place  through  the  skin 
or  mucous  membrane,  through  the  bone  beneath  the  periosteum,  into  a  joint,  into 
the  interior  of  the  skull,  into  the  peritoneal  cavity,  etc.,  or  simply  into  an  area 
where  the  connective  tissue  is  less  dense.  The  mere  diminution  of  pain.  then. 
doe-  not  necessarily  mean  a  betterment  of  the  condition  ;  it  may  be  an  indication 
that  the  pus  has  invaded  new  and  perhaps  far  more  important  structure-,  and 


80         DISEASES    CAUSED    BY    THE    PUS-PRODUCING   BACTERIA 

that  locally  the  tension  is  thus  relieved.  When  poultices  were  commonly  used 
in  the  early  stage  of  the  abscess,  the  heat  and  moisture  often  broke  down 
nature's  limiting  barriers,  permitted  the  pus  to  burrow  into  the  surrounding 
structures,  and  thus  caused  temporary  diminution  of  pain. 

The  pain  of  abscess  is  usually  of  a  throbbing,  boring  character,  and  is 
commonly,  though  not  always,  felt  at  the  site  of  the  inflammatory  focus.  It  is 
often  worse  at  night,  and  is  generally  somewhat  relieved  by  the  maintenance 
of  a  posture  diminishing  the  arterial  blood-pressure  and  favoring  venous  return 
by  gravity — for  example,  by  vertical  suspension  of  a  hand  and  arm,  the  seat 
of  abscess.  There  are,  however,  many  exceptions  to  this  rule ;  Avhere  abscess 
presses  upon  the  nerves,  the  pain  may  be  felt  over  the  whole  or  a  part  of  the 
distribution  of  the  nerve,  and  thus  be  felt  in  situations  far  removed  from  the 
focus  of  inflammation.  Thus,  pain  of  an  abscess  at  the  root  of  a  tooth  is  not 
infrequently  felt  over  the  entire  distribution  of  the  fifth  nerve  of  that  side. 
The  pain  of  abscess  in  or  near  the  hip- joint  is  often  felt  in  the  knee.  The 
pain  of  abscess  of  the  prostate  is  often  most  severe  in  the  glans  penis  and  in 
the  rectum,  and  the  pain  of  abscess  of  the  kidney  is  frequently  severe  in  the 
urinary  bladder.  The  individual  instances  of  the  type  of  referred  pain  will 
be  discussed  under  Regional  Surgery.  The  pain  of  abscess  appears  to  be 
almost  entirely  due  to  pressure  upon  the  nerves  of  the  inflamed  part,  especially 
to  the  infiltration  and  pressure  of  the  inflammatory  exudate  upon  the  smaller 
nerves.  If  this  tension  is  relieved  by  incision  or  rupture  of  the  abscess,  the 
pain  diminishes  rapidly,  and  often  entirely  disappears  at  once  or  in  a  few 
hours. 

Heat. — In  addition  to  the  general  rise  of  body  temperature,  a  part  of  the 
seat  of  abscess  is  supplied  with  an  increased  amount  of  blood,  and  is  warmer 
to  the  touch  than  the  surrounding  tissues.  When  an  abscess  is  superficial,  this 
increase  of  temperature  is  readily  appreciated  by  the  hand  laid  upon  the  part, 
or  if  less  marked  one  hand  may  be  laid  upon  the  corresponding  part  of  the 
body  of  the  healthy  side,  and  thus  the  difference  in  temperature  may  be  appre- 
ciated. A  surface  thermometer  may  even  be  used  for  the  same  purpose.  The 
increased  local  heat  can  only  be  appreciated  in  case  the  abscess  is  near  the  sur- 
face ;  in  cases  of  abscess  of  deep-seated  tissues  and  organs  it  will  not  be  present. 

Redness. — Redness  of  the  skin  is  present  in  superficial  abscesses.  If  the 
abscess  is  immediately  beneath  the  skin,  the  color  will  be  of  a  bright  and  vivid 
red,  often  sharply  circumscribed  from  the  surrounding  skin  and  unmistakable. 
If  the  abscess  is  more  deeply  seated,  the  redness  will  be  more  diffuse,  less 
vivid,  and  often  so  slight  as  scarcely  to  be  noticeable.  If  the  abscess  has  nearly 
perforated  the  skin,  the  redness  may  be  of  a  dark  or  purple  hue,  and  if  per- 
foration is  about  to  occur,  the  skin  will  be  white,  yellow,  or  blue  over  the 
necrotic  area.  If  the  abscess  be  very  deeply  seated,  no  change  at  all  in  the  color 
of  the  skin  may  be  noted,  and  in  some  of  the  most  violent  suppurative  and 
necrotic  lesions  of  the  subcutaneous  tissues  the  skin  may  be  quite  white  or 
normal  in  appearance. 


PHYSICAL   SIGNS    AND    SYMPTOMS    OF    ACUTE    ABSCESS         31 

The  heal  and  redness  oi  acute  inflammation  and  ab  ce  are  an  expression 
of  the  reaction  of  the  tissues  to  the  noxious  influences  of  the  bacteria;  hence, 
as  might  be  expected,  when  this  reaction  does  nol  occur,  or  i-  bul  slightly 
marked,  these  signs  will  be  absenl  or  less  prominent.  This  is  well  illustrated 
in  some  of  the  secondary  abscesses  occurring  in  the  subcutaneous  tissues,  in 
s c  cases  of  pyemia,  in  many  cases  of  diabetes;  and,  indeed,  under  all  con- 
ditions, when  the  resistance  to  the  Bpread  of  the  pyogenic  process  is  vrv  feeble, 
one  notices  this  absence  of  reaction  on  the  pari  of  tin-  tissues,  notably  in  the 
secondary  pus  infections  following  acute  diseases,  typhoid  fever,  and  in  some 
of  the  pyogenic  infections  occurring  in  locomotor  ataxia,  and  sometimes  in 
the  secondary  abscesses  complicating  erysipelas.  Such  purulenl  collection-  may 
only  lie  discovered  by  accident,  a  very  little  tenderness  and  a  boggy  or  fluctu- 
ating swelling  being  the  sole  indications  of  the  presence  of  pus.  Upon  incising 
such  abscesses,  the  pus  will  lie  found  existing  under  very  little  ten-ion,  the 
walls  of  the  abscess  will  he  necrotic,  and  little  or  no  evidence  of  an  effort  to 
limit  the  spread  of  the  inflammation  on  the  part  of  the  tissues  will  he  observed. 
Such  a  want  of  reaction  is,  in  general,  indicative  of  feehle  vitality,  and  is  of 
rather  unfavorable  prognostic  significance. 

Swelling. — The  swelling  produced  by  abscess  will  vary  according  to  the  size 
and  situation  of  the  purulent  focus,  according  to  the  severity  of  the  infection 
and  the  reaction  of  the  tissues,  as  well  as  with  the  character  of  the  tissues  sur- 
rounding the  accumulation.  Sharply  localized  processes,  such  as  furuncle  and 
carbuncle,  produce  under  ordinary  conditions  sharply  defined,  prominent  swell- 
ings.  Abscesses  within  dense,  unyielding  structures  may  produce  no  localized 
swelling  at  all,  or  only  a  swelling  indicating  a  general  interference  with  the 
circulation  of  a  limb.  Thus,  a  long  bone — the  seat  of  acute  purulenl  osteo- 
myelitis— may  not  he  increased  in  size,  hut  often  the  whole  limb  will  be 
swollen  and  the  superficial  veins  dilated  owing  to  the  general  interference 
with  the  venous  circulation.  Wherever  the  tissues  are  lax — as,  for  example, 
the    prepuce,     the    scrotum,     the    eyelids,     and     in    certain     other     regions — the 

swelling   will    he  greal  — oul    of  all    proportion   to   the   size   of   the    purulent 

collect  ion. 

Abscesses  in  the  large  cavities  of  the  body  may  produce  no  visible  nor 
palpable  swelling  at  all,  or  the  swelling  of  the  overlying  soft   parts  may  give 

some  sign  of  the  trouble  within.  An  abscess  within  a  bone  or  bony  cavity,  if 
it  has  existed  for  some  time,  may  produce  absorption  of  bone  with  irritation 
of  the  overlying  periosteum  and  the  production  of  new  bone,  and  the  bone 
may  thus  be  actually  increased  in  size,  and  give  rise  to  a  palpable  and  visible 
enlargement.  In  purulent  collections  in  the  mastoid  process  of  the  temporal 
bone  we  often  see  inflammatory  swelling  and  edema  of  the  overlying  sofl  parts. 
In  purulent  inflammations  of  the  frontal  sinus  and  of  the  antrum  of  High- 
more,  actual  dilatation  ^>i'  the  walls  of  these  cavities  may  take  place  with  cor- 
responding SWellingS  of  the  Surface.  Ill  the  long  holies,  when  purulent  collec- 
tions exist    for  some   time   without    perforating   lb >rtical   layer,   similar   en- 


82        DISEASES    CAUSED   BY   THE   PUS-PRODUCING    BACTERIA 

largements  are  sometimes  observed.  This  is  more  often  the  case  in  tubercular 
and  fibrinous  inflammations  of  these  bones.     (See  Spina  Ventosa.) 

When  a  purulent  focus  exists  in  one  of  the  abdominal  organs,  swelling  may 
sometimes  be  appreciated  by  careful  palpation.  It  will  not  usually  be  possible 
under  such  circumstances  to  do  more  than  make  out  an  enlargement  of  the 
ors;an  in  question,  and  from  concomitant  symptoms,  such  as  tenderness,  rise 
of  temperature,  leucocytosis,  septic  symptoms,  etc.,  to  pronounce  the  probable 
presence  of  pus.  It  sometimes  happens  even  here  that  the  signs  are  sufficiently 
marked  to  render  a  certain  diagnosis  possible,  notably  in  diseases  of  the  uterine 
adnexa,  the  kidney,  the  vermiform  appendix,  etc.  (See  the  Diagnosis  of  Dis- 
eases of  the  Abdomen.) 

Fluctuation. — Fluctuation  is  the  sensation  transmitted  to  the  fingers  when 
pressure  is  made  over  a  cavity  containing  fluid  under  tension.  By  the  pressure 
of  the  fingers  on  one  portion  of  such  a  cavity  the  tension  of  the  fluid  is  in- 
creased, and  this  increase  of  tension  is  appreciated  by  the  finger  or  fingers  of 
the  other  hand  placed  upon  some  other  portion  of  the  wall  of  the  cavity.  The 
fluid  being  incompressible,  the  fingers  are  raised  or  lifted  on  the  one  side  when 
the  wall  of  the  cavity  is  depressed  on  the  ether.  While  the  sensation  of  the 
fluctuation  is  a  valuable  diagnostic  sign  in  cases  of  abscess,  it  must  be  remem- 
bered that  fluids  other  than  pus  give  the  same  sign,  and  that  in  case  the  amount 
of  pus  is  small  and  deeply  seated,  fluctuation  may  be  entirely  absent.  It  would 
be  a  grave  error  to  suppose  that  every  reddened  and  inflamed  area  in  which 
the  sign  of  fluctuation  can  be  detected  is  necessarily  an  abscess,  or,  on  the 
other  hand,  that  the  absence  of  this  sign  indicates  that  no  pus  is  present  or 
that  an  incision  is  uncalled  for.  In  those  forms  of  infection  characterized  by 
a  rapid  spread  of  the  process  with  progressive  necrosis  of  the  tissues,  fluctuation 
may  be  absent  from  first  to  last,  and  fluctuation  may  be  present  where  no  pus 
exists  and  where  an  incision  may  lead  to  disastrous  results.  It  has  happened 
many  times  that  surgeons  have  incised  what  appeared  to  be  an  inflammatory 
tumor  characterized  by  all  the  signs  of  acute  inflammation,  only  to  find  that 
they  have  opened  into  an  aneurism. 

Manifestly,  in  many  regions  of  the  body  the  sign  of  fluctuation  is  obtain- 
able with  difficulty,  if  at  all.  This  is,  of  course,  true  of  purulent  collections 
inclosed  in  bony  cavities,  of  abscesses  deeply  placed  beneath  dense  and  unyield- 
ing structures,  even  though  these  be  quite  superficial,  as,  for  example,  in  the 
palm  of  the  hand  and  in  the  submaxillary  triangle  of  the  neck ;  and  in  many 
other  situations  the  mere  thickness  of  the  tissues  intervening  between  the  ex- 
amining hand  and  the  purulent  focus,  together  with  the  increased  resistance 
due  to  inflammatory  infiltration,  will  render  the  appreciation  of  the  sense  of 
fluctuation  difficult,  uncertain,  and  even  impossible.  If  other  signs  and  symp- 
toms indicating  the  presence  of  pus  are  present,  it  is  unwise  and  irrational 
under  many  conditions  to  wait  for  this  sign.  In  the  examination  of  inflamed 
joints  for  the  detection  of  fluid,  the  sign  of  fluctuation  is  sometimes  of  great 
value.     It  is  sometimes  possible  by  making  pressure  with  the  fingers   over 


PHYSICAL   SIGNS    AND    SYMPTOMS    OF    ACUTE    ABS<  I 

several  portions  of  the  joint  al  the  .-; •  time  to  elicil  this  Bign  with  certainty. 

A  more  detailed  description  of  the  method  will  be  given  under  Regional  Sur- 
gery and  under  I  diseases  "I  Joinl  -. 

Tenderness.— A  very  valuable  sign  of  the  probable  presence  of  pus  in  an 
acutely  inflamed  area  is  the  detection  of  a  fixed  poinl  oi  extreme  tenderness. 
In  many  situations,  when  taken  together  with  other  signs  of  purulenl  infection, 
such  a  poinl  of  tenderness  i-  of  the  utmosl  diagnostic  value,  uol  only  indicating 
ili,.  probable  presence  of  pus,  bul  also  furnishing  the  surgeon  with  ;i  reliable 
guide  to  the  position  of  bis  incision.  This  bolds  true  uol  only  of  the  more 
superficial  abscesses,  bul  also  of  those  more  deeply  situated.  It  points  to  the 
place  foT  incision  as  well  in  abscesses  in  the  pulp  of  the  finger  as  in  cases  of 
osteomyelitis  of  the  long  bones  and  inflammations  of  the  interior  of  the  abdo- 
men- as,  for  example,  in  abscesses  in  the  neighborhood  of  the  vermiform 
appendix.  Of  all  the  signs  of  the  presence  of  pus,  this  is  perhaps  the  raosl 
valuable.  Other  local  signs  of  suppuration  will  be  mentioned  in  their  appro- 
priate places. 

Special  Symptoms  of  Acute  Abscess. — Other  special  symptoms  may  be  pro- 
duced by  the  pressure  of  inflammatory  exudates  including  abscess — for  exam- 
ple, interference  with  the  function  of  nerve  trunks  by  pressure,  causing  partial 
<>r  complete  paralysis  of  the  region  supplied  by  the  nerve,  either  sensory  or 
meter;  interference  with  the  caliber  of  hollow  viscera,  such  as  the  trachea, 
causing  dyspnea,  or  the  intestine,  causing  complete  or  partial  occlusion  of  its 
lumen.  The  pressure  of  a  purulent  collection  within  the  cranium  may  cause 
the  most  varied  symptoms  <\wr  to  the  inhibition  of  the  function  of  any  portion 
of  the  cerebrum  or  any  of  the  cranial  nerves.  Under  such  circumstances  it  is 
obvious  that  a  focus,  even  of  small  size,  may  give  rise  to  serious  or  even  fatal 
symptoms. 

Pressure  upon  blood-vessels — notably  veins- — may  give  rise  to  disturbance 
of  the  function  of  the  limb,  to  great  swelling  and  edema,  and  dangerous  dis- 
turbances of  nutrition.  Abscess  in  the  neighborhood  of  the  urethra  and  in  the 
prostate  may  often  cause  retention  of  urine.  Purulent  collection-  in  joints 
Usually  cause  total  or  partial  loss  of  function  in  the  joint  involved.  The  dis- 
tention of  the  joint  causes  severe  pain,  and  (he  individual  involuntarily  places 
the  joint  in  such  a  position  as  to  relieve  such  tension  as  far  a-  may  he;  the 
muscles  of  the  limb  are  spasmodically  contracted  when  passive  effort-  are  made 
to  move  (he  joint  surfaces  en,,  upon  the  other,  and  the  limb  is  thus  held  rigidly 
fixed.  Crowding  the  surface-  of  an  inflamed  joint  together  also  gives  rise  to 
extreme  pain. 

The  Use  of  the  Aspirating-  Needle. —  An  ordinary  hypodermic  syringe,  or  one 
of  larger  size,  armed  with  a  hollow  needle  of  variable  length,  according  to  the 

thickness  of  the   tissue-    to  he   penetrated.    i<   milch    \\<i-<]    for   diagnostic    pur: 

to    determine    the    presence    or    ah-ellce    of    pus,    or    the    character    of    a    tlllid    cell 

tained  in  an  inflamed  area,  in  a  joint,  in  a  tumor,  in  the  pleural  cavity,  or  in 
certain  of  the  solid  organs  of  the  abdomen.     The  method  of  its  use  is  simple. 


84        DISEASES    CAUSED   BY   THE   PUS-PRODUCING   BACTERIA 

The  syringe  and  needle,  properly  sterilized — best  by  boiling — is  tbrust  into 
the  suspected  tissues,  cavity,  tumor,  or  organ,  as  the  case  may  be,  the  surface 
of  the  skin  having  been  carefully  scrubbed  and  disinfected  beforehand,  and  the 
entire  procedure  being  made  with  the  same  precautions  which  would  properly 
accompany  a  surgical  operation.  The  piston  of  the  syringe  is  slowly  drawn 
out  of  the  barrel,  thus  aspirating  any  fluid  thin  enough  to  pass  through  the 
needle  into  the  barrel  of  the  syringe,  so  that  its  character  may  be  observed 
and  studied. 

The  method  is  used  to  a  great  extent  to  determine  the  character  of  exudates 
in  the  pleural  cavity,  occasionally  the  quality  of  the  fluid  contained  in  an 


Fig.   16. — Potaix's  Aspirator.     (W.  F.  Ford  &  Co.) 


Fig.   17. — Diettlafoy's  Aspirator.     (W. 
Ford  &  Co.) 


inflamed  joint,  and  sometimes  in  cases  of  suspected  abscess  of  the  liver.  It  is 
sometimes  used  to  detect  the  presence  of  pus  in  ordinary  superficial  abscesses. 
It  may  be  a  valuable  guide  to  the  situation  of  a  purulent  collection  when  the 
amount  of  swelling  or  edema  is  great  and  the  exact  situation  of  the  purulent 
focus  is  doubtful.  In  certain  deep-seated  abscesses  of  the  neck,  accompanied 
by  much  swelling  and  brawny  edema,  the  use  of  the  aspirating  needle  is  at 
times  not  only  justifiable,  but  desirable.  In  some  of  these  cases  the  purulent 
exudate  is  small  and  the  inflammatory  infiltration  is  very  extensive,   and  a 


DISEASES    <<r    WOUNDS 

single  drop  of  pus  aspirated  through  a  oeedle  may  afford  n  valuable  indication 
of  the  depth  and  situation  of  the  abscess.   The  fallacies  connected  with  tin-  u 
the  aspirating  needle  are:  the  purulent  focus  may  be  missed  entirely;  the  pus 

may  be  too  thick  to  enter  the  oeedle ;  a  blood  vessel  may  be  punctured,  and  U I 

instead  of  pus  may  be  obtained,  although  pus  may  exisl  at  another  level. 

The  dangers  in  the  use  of  the  aspirating  needle  are:  the  infectious  material 
may  be  carried  into  new  and  more  dangerous  regions;  importanl  vessels  or 
nerves  may  be  wounded;  it'  an  abscess  cavity  is  entered  and  the  needle  with- 
drawn, Leakage  of  the  pus  may  occur  into  a  large  body  cavity,  sometimes  with 
dangerous  or  fatal  results  unless  the  aspiration  is  followed  at  once  by  incision. 
Under  no  circumstances  should  an  aspirating  nee. lie  be  thrust  into  the  peri- 
tonea] cavity  unless  absolute  certainty  exists  that  the  organ  to  be  explored  is 
adherent  to  the  parietal  peritoneum  over  a  considerable  area.  During  opera- 
tions upon  the  abdomen,  on  the  other  hand,  the  aspirating  needle  is  of  great 
use  under  a  variety  of  conditions,  which  will  he  spoken  of  under  Regional 
Surgery.  It  is  also  valuable  in  determining  the  character  of  fluid  accumu- 
lations, other  than  pus,  in  many  conditions. 


DISEASES    OF    WOUNDS 

Aseptic    Wound    Fever,    Sapbemia,    Septic    Intoxication,    Septicemia, 
Pyemia,   and   their   Combinations 

This  most  important  group  of  constitutional  disturbances  following  wounds 
may  he  conveniently  considered  together. 

Aseptic  Wound  Fever. — As  its  name  implies,  aseptic  wound  fever  is  used 
to  designate  certain  constitutional  disturbances  sometimes  observed  after  in- 
juries, whether  open  wounds  or  subcutaneous  traumatisms,  unaccompanied  by 
bacterial  infection.  Other  names  which  have  been  given  to  it  are  Ferment 
Fever  (von  Bergmann),  Resorption  Fever,  After  Fever  |  Billroth).  The  symp- 
toms are  observed  most  often  where  a  considerable  quantity  of  effused  blood 
exists  in  the  depths  of  a  wound,  or  where,  in  the  ease  of  a  subcutaneous  injury, 
much  blood  is  extravasated  into  the  tissues.  It  was  formerly  believed  that  the 
symptoms  were  caused  by  the  absorption  of  the  fibrin  ferment  formed  in  the 
extravasated  blood.  At  present  it  is  believed  to  be  caused  by  the  absorption 
of  nucleins  ami  albumoses,  substances  occurring  in  such  blood,  and  identical 
symptoms  have  been  produced  by  the  introduction  of  these  substances  into  the 
circulation  of  animals.  The  condition  may  be  almost  absent  after  severe  oper- 
ations, or  may  follow  comparatively  trifling  operative  procedures.  Imperfect 
heniostasis,  bruising  and  strangulating  of  tissues  favor  its  occurrence. 

Symptoms  of  Aseptic  Wound  Fever. — The  symptoms  are  as  follows: 
Within  twenty-four  hours,  usually,  after  the  injury  or  the  operation  the  tem- 
perature of  the  patient  rises  to  100°  or  101°  or  102  1'..  seldom  higher.  The 
pulse  also  becomes  correspondingly  rapid;  the  patient's  face  is  often  flushed; 


86 


DISEASES    CAUSED   BY   THE   PITS-PRODUCING   BACTERIA 


there  is  sometimes  slight  headache.  Usually  the  subjective  symptoms  are  so 
slight  that  the  patient  feels  quite  well  and  comfortable ;  the  temperature  usually 
falls  to  normal  within  forty-eight  hours,  unless  some  other  cause  for  the  con- 
tinuance of  the  fever  is  present  or  is  developed.  The  signs  and  symptoms  of 
wound  infection  are  absent.  Some  slight  disturbance  of  this  kind  is  the  rule 
rather  than  the  exception  after  surgical  operations  of  any  considerable  mag- 
nitude, and  does  not  give  rise  to  anxiety  on  the  part  of  the  surgeon. 

In  some  cases  the  symptoms  will  be  more  marked.     The  patient  will  com- 
plain of  pain  and  of  a  feeling  of  tension  in  the  wound.     An  examination  of 


February 

6 

7 

8 

9 

10 

11 

12 

Day  of  Disease 

1 

2 

3 

4 

Hour 

8 

8 

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S 

s 

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104° 

103° 

102° 

101° 

100° 

99° 

98° 

97° 

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Fig.  18. — Temperature  Chart  of  a  Case  of  Aseptic  Wound  Fever. 


the  wound  upon  the  following  day  will  show  the  suture  line  not  reddened,  but 
the  surrounding  area  may  appear  unduly  prominent,  and  a  sense  of  fluctuation 
may  be  transmitted  to  the  examining  fingers.  The  wound  will  be  found  dis- 
tended with  bloody  serum,  or  with  fluid  blood  or  partly  clotted  blood.  Evacu- 
ation of  the  foreign  material  will  be  followed  by  a  subsidence  of  the  fever,  and 
if  the  wound  remains  clean  the  temperature  will  not  rise  again.  The  recog- 
nition of  such  a  state  of  affairs  is  highly  important,  because  while  operative 
wounds  heal  under  proper  conditions  without  giving  evidences  of  the  presence 
of  bacteria,  yet  our  technic  is  not  so  perfect  as  to  exclude  all  germs  from 
wounds ;  and  while  a  clean,  dry  wound  in  which  a  few  bacteria  of  suppuration 


DISEASES    OF    WOUNDS 

are  presenl  will  often  heal  per  primam,  the  presence  of  a  considerable  quantity 

iif  hi I  in  the  wound  will  greatly   favor  the  multiplication  of  Buch  bacteria 

as  may  be  present,  and  wound  infection  may  follow  unless  the  blood  be  rem* 
;it  ;m  early  date. 

The  accompanying  temperature  charl  represents  the  course  of  aseptic  wound 
fever  as  ordinarily  observed.  The  charl  is  thai  "I  a  case  in  which  an  operation 
for  the  radical  cure  of  inguinal  hernia  was  done  upon  a  healthy  male  adult. 
Primary  union  occurred  in  the  wound. 

Sapremia — Putrid  Intoxication. — Sapremia  is  the  name  used  to  designate 
the  condition  produced  by  the  absorption  into  the  system  "I  the  excretory  prod- 
ucts of  the  saprophytic  bacteria-  the  bacteria  whose  growth  takes  place  in  dead 
organic  matter,  the  bacteria  of  putrefaction.  Ii  is  probable  thai  ;i  pure  sapre- 
mia— that  is  to  say,  a  condition  of  poisoning  due  to  the  saprophytes  alone 
without  the  additional  toxemia  of  one  or  more  of  tli*'  pus-producing  organisms 
— is  a  comparatively  rare  occurrence.  The  disease  is  an  acute  poisoning  due 
l<>  tlic  presence  in  the  body  of  putrefactive  material.  Such  material  may  be 
n  putrid  blood  clot  in  the  depths  of  a  contused  wound,  a  mass  of  decomposed 
placenta  in  the  parturient  uterus,  a  gangrenous  limb,  or  ;i  strangulated  coil  of 
gu1  in  ;i  hernial  sac,  or  sonic  other  mass  of  dead  tissue  in  which  the  bacteria 
of  putrefacl  ion  are  mull  iplying. 

Symptoms  of  Sapremia. —  In  most  cases  the  history  and  local  findings 
are  sufficient  to  point  (dearly  to  the  source  of  the  poison.  The  symptoms  of 
the  disease  are  those  of  a  fairly  sudden  intoxication.  In  .some  cases  a  rapid 
rise  of  temperature  will  be  the  first  symptom.  In  others  the  fever  will  be 
preceded  by  loss  of  appetite,  headache,  and  prostration;  the  temperature  may 
pise  in  a  few  hours  to  104°  or  even  L06  F. ;  the  pulse  will  be  accelerated  to  a 
corresponding  extent.  Sometimes  the  rise  of  temperature  is  accompanied  by 
a  chill.  In  the  mosl  severe  cases,  such  as  may  follow  putrefactive  changes  sud- 
denly taking  place  in  a  crushed  or  strangulated  extremity,  the  absorption  of 
the  products  of  putrefaction  may  be  so  rapid  that  death  occurs  in  a  day  or  two. 
After  the  initial  chill  and  rise  of  temperature  the  entire  organism  may  be 
overwhelmed  by  the  poison.  The  patient  will  become  delirious  in  a  few  hours; 
the  delirium  may  pass  rapidly  into  stupor  or  coma.  The  circulation  will  be 
profoundly  affected  from  the  outset;  the  heart  will  beal  rapidly,  and  speedily 
become  more  and  more  feeble;  the  surface  of  the  body  will  be  cold,  bathed  in 
a  clammy  sweat,  and  pale  or  cyanotic.  The  expression  of  the  face  will  be  dull 
and  apathei  ie. 

The  onset  of  the  symptoms  may  be  so  sudden  and  severe  as  to  resemble  the 
condition  of  shock.  Death  may  take  place  from  failure  of  the  heart,  sometimes 
with  a  very  high  temperature  and  sometimes  with  a  temperature  which  is  sub- 
normal. Such  a  violent  course  is,  however,  uncommon.  Usually  following 
the  chill  and  fever  there  will  he  marked  prostration,  headache,  vomiting, 
diminution  in  the  excretion  of  the  urine,  sometimes  diarrhea.  The  headache 
will  he  followed  by  delirium,  restlessness,  later  h\  coma,  a  rapid  and  failing 


88        DISEASES    CAUSED   BY   THE   PUS-PEODUCING   BACTEEIA 

pulse,  and  death.  In  other  cases,  if  the  amount  of  putrid  material  be  small, 
the  process  may  be  self-limiting.  The  bacteria  may  use  up  the  pabulum  neces- 
sary for  their  further  propagation;  the  poisons  will  cease  to  be  manufactured 
and  absorbed,  and  the  individual  recover. 

Diagnosis  of  Sapremia. — It  is,  however,  by  the  results  of  surgical  inter- 
ference that  the  diagnosis  may  be  most  clearly  established  and  the  presence  of 
the  pus-producing  bacteria  as  active  elements  in  the  condition  may  be  elim- 
inated. If  the  case  be  one  of  pure  sapremia,  the  operative  removal  of  the 
dead  material  will  usually  be  followed  by  an  immediate  subsidence  of  all 
the  symptoms.  The  general  condition  of  the  patient  rapidly  improves;  the 
fever  subsides,  and  does  not  return.  The  diagnosis  of  sapremia  is  to  be  made 
then  in  the  presence  of  a  focus  of  dead  material  within  the  body.  The  signs 
of  putrefaction — a  putrid,  foul,  or  disagreeable  odor — will  be  present  if  the 
focus  communicates  with  the  exterior  of  the  body.  A  wound  will  usually  be 
tender  and  painful,  and  will  give  forth  a  thin  and  watery,  or  blood-stained, 
evil-smelling  discharge.  The  constitutional  symptoms  will  vary  in  severity, 
as  described,  according  to  the  amount  of  putrid  material,  the  activity  of  the 
bacteria,  and  the  size  and  character  of  the  absorbing  surface.  Should  the 
symptoms  continue  after  the  dead  material  is  removed,  we  may  assume  that 
the  pus-producing  organisms  are  also  concerned  in  the  process. 

The  following  history  and  temperature  chart  represent  very  well  a  typical 
case  of  sapremia : 

A.  J.,  aged  twenty-seven,  had  been  pregnant  for  two  months  when  she  began 
to  bleed  from  the  uterus.  The  bleeding  continued  for  several  days,  without  other 
symptoms,  when  she  was  examined  and  treated  by  a  physician.  Two  days  later 
she  was  seized  with  a  violent  chill,  followed  by  fever  and  profuse  sweating,  vomit- 
ing, and  prostration.  A  second  chill  occurred  in  twelve  hours,  and  bleeding  recom- 
menced. On  the  following  day  she  was  brought  to  the  hospital  by  the  ambulance. 
At  this  time  her  temperature  was  104°  F. ;  her  pulse  108 ;  she  complained  of  head- 
ache; her  face  was  flushed.  There  was  a  discharge  of  blood  from  the  uterus  of 
moderate  quantity  which  gave  out  a  faint  odor  of  decomposition.  The  uterus  was 
moderately  enlarged,  soft,  and  tender.  The  contents  of  the  uterus  were  imme- 
diately evacuated.  The  contents  consisted  of  decidual  and  fetal  tissues  in  a  state 
of  decomposition.  Four  hours  afterwards  the  patient's  temperature  had  fallen  to 
98°  F.,  and  did  not  rise  again  above  99°  F.  The  pulse  also  had  fallen  in  sixteen 
hours  to  72,  where  it  remained.    The  jjatient  had  no  further  pathological  symptoms. 

Typical  Characters  of  Septic  Diseases. — By  septic  intoxication  we  understand 
the  symptoms  produced  by  the  absorption  from  a  focus  of  suppuration  of  the 
toxic  products  elaborated  in  the  tissues  by  the  pus-producing  organisms.  We 
use  this  term  mainly  for  the  purpose  of  excluding  those  cases  in  which  the 
bacteria  have  entered  the  circulating  blood  in  large  numbers,  or  have  caused 
new  foci  of  inflammation  in  distant  parts.  By  septicemia  we  understand  that 
form  of  infection  in  which  living  pus  microbes  exist  and  multiply  in  the  blood. 
By  pyemia  we  mean  that  form  of  blood-poisoning  in  which  the  pus  microbes, 


DISEASES   OF   WOUNDS 


89 


having  entered  the  blood  cm-rent  from  a  local  focus  of  suppuration,  either 
directly  or  through  the  medium  of  the  lymphatic  channels,  are  carried  to  and 
lodge  in  distanl  organs,  there  to  form  new  foci  of  suppuration.  Clinically  it  is 
urn  always  possible  to  separate  septicemia  and  pyemia.  In  certain  cases  the 
two  coexist,  and  we  speak  then  of  septico-pyemia. 

Blood  Cultures  in  Septic  Diseases. —  In  septic  diseases  of  a  severe  grade  caused 
by  the  pus-producing  bacteria — i.e.,  in  true  septicemia,  from  whatever  local 
lesi<m,  and  pyemia — it  is  possible  to  demonstrate  the  presence  of  one  or  other 
of  the  forms  of  pyogenic  cocci  in  the  blood   in  ;i  considerable  proportion  of 


January 

23 

24 

25 

26 

27 

28 

29 

Day  of  Disease 

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Fig.  19. — Temperature  Chart  of  a  Case  of  Sapremia. 


cases.  It  was  formerly  believed  thai  in  septicemia  Mood  cultures  were  very 
rarely  successful,  except  during  the  hist  days  of  the  disease,  and  that  the  mosl 
favorable  time  for  making  the  examination  was  during  or  shortly  after  the 
occurrence  of  a  chill.  At  the  present  time,  when  it  is  customary  to  use  large 
quantities  of  blood  for  the  preparation  of  cultures,  it  has  been  found  that  such 
cultures  are  successful  in  a  large  proportion,  certainly  more  than  one  half, 
of  pronounced  cases  of  septicemia  at  some  time  during  the  disease,  and  in 
many  instances  such  cultures  give  positive  results  at  every  trial.  Tin 
is  a  valuable  one,  since  by  identifying  the  bacteria  found  in  the  circulating 
blood  we  are  aide  to  form  a  fairly  good  idea  of  the  prognosis.     It  i-.  for  exam- 


90 


DISEASES    CAUSED    BY    THE    PITS-PRODUCIXG   BACTERIA 


pie,  well  known  that  the  presence  of  streptococci  in  pure  cultures  in  the  blood 
is  of  more  unfavorable  significance  thau  is  the  case  with  most  other  forms 
of  pyogenic  germs.  In  a  number  of  instances  under  my  care  in  the  Xew  York 
Hospital  the  Staphylococcus  pyogenes  aureus  has  been  demonstrated  in  the 
blood  on  several  occasions,  and  vet  the  patient  has  recovered.  Such  has  not 
been  the  case  when  streptococci  were  demonstrated.  It  is  rarely,  if  ever,  possi- 
ble to  discover  bacteria  in  the  circulating  blood  by  cover-glass  smears. 

Method  of  Pkoceduke  in"  Making  Blood  Cultukes. — The  utmost  care 
must  be  taken  to  disinfect  the  patient's  skin  at  the  place  where  the  blood  is  to 
be  withdrawn,  and  scrupulous  attention  should  be  paid  to  the  details  of  aseptic 
technic  in  performing  the  operation.  A  vein  at  the  bend  of  the  elbow  is  ordi- 
narily used  as  a  source  of  the  blood.  The  vein  should  be  exposed  through  a 
small  incision  in  the  skin,  and  the  blood  to  a  quantity  of  at  least  20  c.c.  may 
be  drawn  into  the  barrel  of  a  large  aspirating  syringe,  which  must  be  certainly 
sterile,  through  an  aspirating  needle  thrust  into  the  caliber  of  the  vein ;  the 

apparatus  known  as  Thatcher's  "  mos- 
quito," or  Ewing's  pipette,  may  be  used. 
The  needle  or  the  mosquito  is  thrust 
into  the  vein  and  the  blood  flows  into 
the  flask;  1  c.c.  of  this  blood  is  added 
to  100  c.c.  of  broth  or  other  fluid  culture 
medium  in  a  suitable  flask.  Three  such 
flasks  are  usually  prepared  and  placed 
in  the  incubator.  Should  a  growth 
occur  in  the  medium,  the  bacteria  are  to 
be  identified  in  the  pathological  labora- 
tory by  the  ordinary  methods. 

Septic  Intoxication. — The  condition 
of  septic  intoxication  is,  of  course,  pres- 
ent to  a  greater  or  less  extent  when- 
ever an  acute  infection  by  pus-producing 
germs  exists  anywhere  in  the  body.  Septic  intoxication  may  therefore  exist 
of  every  grade  of  severity  from  the  scarcely  perceptible  fever  and  malaise  which 
may  accompany  a  small  and  slightly  infected  superficial  wound,  or  the  presence 
of  an  insignificant  furuncle,  or  a  subcutaneous  abscess  in  loose  tissues,  to  the 
fulminating  cases  of  peritoneal  sepsis  following  the  sudden  invasion  of  the 
peritoneal  cavity  by  an  overwhelming  dose  of  bacterial  toxins,  such  as  may 
destroy  life  in  a  few  hours.  The  violence  of  the  symptoms  will  be  modified 
by  a  great  variety  of  factors  which  we  have  considered  elsewhere.  In  general, 
the  intensity  of  the  constitutional  reaction  is  modified  by  the  size  of  the  dose 
of  bacterial  toxins  and  by  the  virulence  of  the  bacteria,  as  well  as  by  a  number 
of  local  conditions — as,  for  example,  the  existence  of  tension  in  the  inflamma- 
tory focus.  A  small  abscess  the  walls  of  which  are  in  unyielding  tissues,  so 
that  the  contained  pus  is  in  a  condition  of  tension,  may  cause  constitutional 


Fig.  20. — Thatcher's  "Mosquito." 


DISEASES    OF    WOUNDS  91 

symptoms  of  ;i  degree  of  severity  oul  of  ;ill  proportion  to  the  3ize  of  the  inflam- 
matory locus.  The  absorbing  power  of  certain  tissues  and  of  the  walls  of  cer- 
tain body  cavities  apparently  has  much  to  do  with  the  rapidity  of  the  absorp- 
tion of  toxic  products;  for  example,  the  serous  membranes  of  the  cranium  and 
of  the  peritoneum,  as  well  as  the  synovial  membranes  of  joints,  are  known  to 
be  of  a  character  favoring  the  rapid  absorption  of  toxins. 

Constitutional  Symptoms  of  Septic  [ntoxication. — These  consist  of 
the  symptom  i iplex  known  as  fever,  and  others.  The  fever  i<  usually  continu- 
ous, with  remissions;  lower  in  the  morning  and  higher  in  the  evening.  It  may 
be  intermittent,  with  more  or  less  sudden  exacerbations.  If  the  disease  is  to  be 
fatal,  the  fever  frequently  Bhows  an  upward  tendency,  and  may  rise  to  a  high 
degree  jusl  before  death.  The  evacuation  or  removal  of  the  inflammatory  focus 
is,  in  pure  septic  intoxication,  followed  by  a  rapid  fall  of  the  fever.  In  some 
instances,  after  an  abscess  is  opened  and  drained — notably  if  much  tension  has 
been  present — the  temperature  will  fall  almost  or  quite  to  normal  at  once,  and 
remain  there.  If  the  incision  of  an  inflammatory  focus  has  involved  the 
opening  up  of  many  lymph  spaces,  a  temporary  increase  in  the  fever  may 
occur,  to  be  speedily  followed  by  a  fall  of  temperature  to  or  near  the  normal. 
The  pulse  is  increased  in  rapidity.  If  the  degree  of  intoxication  is  moderate, 
the  pulse  will  be  full.  In  more  severe  cases  the  pulse  will  be  not  only  rapid, 
but  feeble.  In  fatal  eases  the  pulse  will  grow  more  rapid  and  more  feeble  and 
compressible  until  death.  In  general,  the  height  of  the  temperature  and  the 
rapidity  and  character  of  the  pulse  vary  together.  A  high  temperature  will 
be  accompanied  by  a  correspondingly  rapid  pulse;  this  relation  is,  however, 
not  constant.  In  many  sudden  and  severe  cases,  where  a  large  dose  of  septic 
material  enters  the  circulation,  the  pulse  may  be  rapid  and  feeble,  while  the 
temperature  is  but  little  elevated.  Such  a  want  of  correspondence  between  the 
temperature  and  the  pulse  sometimes  indicates  an  overwhelming  dose  of  poison, 
and  may  be  of  the  gravest  significance;  it  is  noted  especially  in  perforation 
peritonitis. 

Accompanying  the  rise  of  temperature  and  increased  rapidity  of  the  pulse 
there  are  other  and  varied  symptoms  and  signs,  presently  to  be  described.  It 
is  to  be  borne  in  mind  that  clinically  we  are  not  always  able  to  separate  cases 
of  septic  intoxication  from  those  of  septicemia.  If,  after  the  relief  of  the 
tension  and  the  evacuation  of  an  inflammatory  focus  by  suitable  means,  the 
fever  and  other  symptoms  speedily  subside  and  recovery  takes  place,  septicemia 
did  not  exist.  In  many  instances  we  are  unable  at  once  to  fulfill  perfectly  the 
indications  of  drainage  and  the  relief  of  tension.  The  symptoms  persist,  and 
we  cannot  at  once  exclude  septicemia. 

Septic  Intoxication  as  the  Ivf.st^t.t  of  Erroes  in  Aseptic  Technic. — 
As  the  result  of  error-  in  aseptic  technic,  cases  of  moderate  septic  intoxica- 
tion are  occasionally  seen  in  surgical  work.  Following  an  operative  wound 
upon  clean  tissues,  a  patient  complains  after  forty-eight  hours  of  a  sense  ,>{ 
discomfort    in   the  wound,   a   sense  of   fullness   or   tension  or  slight    pain.      The 


92        DISEASES    CAUSED   BY   THE   PUS-PRODUCING  BACTERIA 

evening  temperature  upon  the  second  day  is  100°  F. ;  the  pulse,  86.  Upon  the 
third,  day  the  temperature  in  the  evening  is  101°  F. ;  pulse,  95.  The  patient 
has  no  desire  for  food;  he  drinks  much  water;  his  tongue  is  coated.  He  is 
somewhat  restless  at  night.  His  face  is  a  little  flushed,  his  eyes  bright.  The 
sense  of  fullness  in  the  wound  continues,  but  there  is  no  severe  pain.  Perhaps 
his  malaise  and  fever  are  attributed  to  autointoxication  caused  by  imperfect 
action  of  the  bowels,  and  appropriate  means  are  used  to  cause  the  bowels  to 
move  freely.  The  temperature  and  pulse  remain  elevated,  however,  and  the 
patient  after  a  day  or  two  more  complains  a  good  deal  of  pain  in  the  wound, 
and  begins  to  feel  really  ill.  He  has  headache.  The  urine  is  scanty  and  high- 
colored.  He  has  a  positive  distaste  for  food,  but  complains  a  good  deal  of 
thirst. 

Upon  examination  the  wound  edges  may  be  found  reddened,  swollen,  and 
tender.  The  swelling  has  caused  undue  tension  of  the  skin  sutures,  and  the 
swollen  skin  is  puckered  at  the  sutured  points.  Removal  of  one  or  more  sutures 
and  separation  of  the  wound  edges  permit  the  escape  of  a  moderate  quantity  of 
yellow  or  blood-stained  pus  from  the  subcutaneous  wound  cavity.  The  exposed 
tissues  do  not  appear  necrotic,  nor  much  infiltrated.  Here  and  there  at  the 
site  of  ligatures  a  minute  mass  of  necrotic  tissue  may  appear  as  the  center 
from  which  the  infection  started,  or  the  walls  of  the  punctures  in  the  tissues 
occupied  by  sutures  at  one  or  several  points  may  be  necrotic,  and  infiltrated 
with  pus.  They  have  evidently  formed  the  centers  from  which  the  infection 
started.  In  other  cases  the  skin  and  subcutaneous  tissue  will  be  free  from 
signs  of  inflammation,  but  pressure  will  elicit  marked  tenderness  in  the  deeper 
structures.  Upon  opening  the  wound  a  collection  of  pus  will  be  found  along 
the  suture  line  of  the  muscles.  In  these  mild  cases  of  infection,  evacuation 
of  the  pus  and  relief  of  tension  are  followed  at  once  by  subsidence  of  all  the 
symptoms.  The  wound  edges  become  clean  in  a  few  days,  and  healing  pro- 
ceeds rapidly. 

Combinations  of  Sapremia  with  Septic  Infection,  Saprophytic  and  Pyogenic 
Infection. — In  a  large  number  of  cases  combinations  of  pyogenic  and  sapro- 
phytic infections  occur;  the  resulting  local  lesion  and  systemic  poisoning  may 
be  of  any  possible  degree  of  severity.  Some  of  the  more  severe  forms  have 
been  described  under  Moist  Gangrene,  Acute  Emphysematous  Gangrene,  and 
kindred  lesions.  The  less  severe  forms  are  very  common  as  the  result  of  acci- 
dental crushing  injuries — such  injuries,  for  example,  as  extensive  contusion 
and  laceration  of  the  soft  parts  of  a  limb,  with  or  without  destruction  of  the 
main  blood-vessels,  and  compound  fracture  of  one  or  more  bones  of  the  extrem- 
ity.    A  typical  case  of  this  kind  is  the  following: 

M.  B.,  a  vigorous  young  man  of  twenty-eight,  who  had  been  in  perfect  health, 
with  splendid  muscular  development,  was  brought  to  the  hospital  with  the  follow- 
ing history:  A  short  time  before  admission  his  left  upper  arm  had  been  crushed 
in  an  elevator ;  moderate  symptoms  of  shock ;  surface  cool  and  pale :  respiration 
sighing;  temperature,  98.6°  F. ;  pulse,  68;  left  arm,  extensive  contused  and  lacer- 


DISEASES    OF    WOUNDS 

ated  wound  involving  the  Bofl  parte  from  the  junction  of  the  upper  and  middle 
thirds  of  the  humerus  down  to  and  including  the  elbow.  There  was  a  compound 
comminuted  fracture  of  the  Lefl  humerus;  the  upper  half  of  the  bone  was  intact; 
the  lower  half,  including  the  condyles  and  the  olecranon  process  of  ulna,  crushed 
to  numerous  larger  and  smaller  fragments.  The  left  hand  was  pale  and  cold. 
There  was  no  radial  pulse.  Amputation  was  refused.  Cleaning  and  disinfection 
of  wound,  dressing  and  immobilization  of  limb  under  ether  took  place. 

The  following  day  ii  was  evidenl  thai  circulation  in  the  hand  and  forearm  had 
entirely  ceased;  temperature,  L03.8C  I'.:  pulse,  L08.  The  nexi  morning  the  hand 
and  wrist  were  gangrenous,  characteristic  discoloration  was  present,  and  the  wound 
emitted  an  odor  of  putrefaction.  The  upper  arm  was  markedly  Bwollen,  and  the 
skin  showed  a  slight  inflammatory  blush  extending  well  up  toward  the  shoulder. 
An  abundanl  discharge  of  thin,  blood-stained  fluid  escaped  from  the  wound;  the 
odor  of  putrefaction  was  unmistakable.  Temperature  and  pulse  remained  elevated. 
On  ihe  fourth  day  gangrene  had  extended  to  the  elbow.  There  was  marked  cellu- 
litis of  the  upper  arm  as  far  as  the  shoulder.  The  patient  was  much  prostrated 
and  looked  severely  ill.  Amputation  was  now  acceded  to  and  was  done  on  this 
day  at  the  shoulder-joint.  Of  necessity,  the  flaps  contained  infected  tissue;  accord- 
ingly, the  wound  was  left  open  and  packed  with  gauze  wet  with  a  three-per-cent 
solution  of  aluminium  acetate.  Cellulitis  of  the  skin  and  subcutaneous  tissues 
of  the  tlaps  and  some  sloughing  of  the  muscular  Haps  persisted  after  the  ampu- 
tation and  moderate  suppuration  occurred  in  the  wound  for  a  number  of  days. 

Symptoms  of  systemic  infection  continued  fairly  marked  for  two  weeks  and 
gradually  subsided.  The  profound  weakness  and  depression  which  had  existed 
before  the  amputation  as  the  result  of  sapremic  absorption  disappeared  at  once 
after  the  gangrenous  limit  was  removed,  and  though  the  patient  was  profoundly 
anemic  and  lost  a  good  deal  of  flesh,  at  no  time  thereafter  did  the  pyogenic  infec- 
tion threaten  to  destroy  his  life.  The  accompanying  chart  illustrates  the  prompt 
reaction  following  the  accident  almost  at  once  and  due  to  sapremic  poisoning.  The 
symptoms  gradually  merging  into  those  of  pyogenic  infection  reached  a  climax  at 
the  end  of  thirteen  days,  when  a  considerable  pocket  of  pus  was  discovered  in  the 
substance  of  the  deltoid  muscle  and  evacuated,  followed  by  slow  but  continuous 
improvement  for  the  following  fortnight,  when  the  wound  ceased  to  suppurate 
and  the  septic  symptoms  ceased.  Characteristic  leucocytosis  was  present  as  long 
as  suppuration  continued.      (Sec   Fig.  21,  page  !)-f.) 

Local  Signs  of  Septic  Infection. — The  local  symptoms  vary  greatly.  Usually 
there  is  a  wound  or  inflammatory  focus  accessible  to  our  diagnostic  methods 
of  search;  in  some  instances  we  can  only  surmise  the  point  of  origin  of  the 
infection.  If  the  virulence  of  the  poison  is  very  great,  the  constitutional  symp- 
toms may  come  on  suddenly  and  end  in  death  in  a  few  days,  with  trifling  local 
evidence  at  the  point  of  entrance  of  the  poison.  Such  violent  form-  of  infec- 
tion are  occasionally  seen  among  surgeons  and  those  who  make  autopsies  upon 
bodies  just  dead  of  septic  diseases.  The  prick  of  a  needle  upon  the  finger  made 
during  an  operation  upon  a  case  of  acute  osteomyelitis  or  other  intensely  septic 
process,  is  followed  in  a  few  hours  by  a  chill  and  a  rapid  rise  of  temperature; 
prostration   is  marked;   at    the  site  of   inoculation   there   is   to   be  noticed   only 


94 


DISEASES    CAUSED   BY   THE   PUS-PRODUCING   BACTERIA 


slight  redness  and  tenderness,  and  a  few  faint  red  streaks  upon  the  skin  of 
the  arm  along  the  course  of  the  lymphatic  vessels ;  slight  swelling  and  tender- 
ness of  the  lymphatic  glands  of  the  axilla  may  be  noticed.  In  the  course  of 
the  next  twenty-four  hours  the  general  condition  of  the  patient  grows  rapidly 
worse,  delirium  follows  headache,  and  is  soon  succeeded  by  stupor  and  coma. 
The  heart  beats  more  and  more  rapidly  and  feebly,  and  death  occurs  in  a  few 
days  in  collapse,  without  the  development  of  any  noteworthy  local  symptom. 
In  such  cases  the  lymphatics  have  failed  to  furnish  an  efficient  barrier  to  the 
rapid  dissemination  of  the  bacteria  and  their  poisons  throughout  the  body. 

Lymphangitis. — More  commonly  the  local  manifestations  of  an  inocula- 
tion with  pus  microbes  through  a  minute  wound  are  more  marked.     In  twenty- 


Name       MB    Elevat0T  Conductor,  Oct.  28                                                                                                 History  No       s^89§§ 

Compound  comminuted  fracture  of  Humerus,  admitted  April  10,  1905. 

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four  or  forty-eight  hours  after  the. inoculation,  pain,  heat,  redness,  and  swelling 
develop  in  the  neighborhood  of  the  wound.  A  little  discharge,  at  first  of  cloudy 
serum,  then  of  pus,  may  be  evacuated  from  the  puncture  or  abrasion.  The 
patient  soon  begins  to  feel  ill ;  a  chill  may  occur,  more  often  not,  and  there 
will  be  a  rise  of  temperature,  headache,  loss  of  appetite,  prostration.  The  pulse 
will  be  of  a  rapidity  corresponding  with  the  height  of  the  fever,  and  will  usually 
be  full  and  bounding.  If  the  wound  be  upon  the  hand,  red,  tender  streaks  will 
be  noted  running  up  the  forearm  and  the  arm  toward  the  axilla.  The  axillary 
lymph  nodes  will  be  found  tender  and  swollen.  The  epitrochlear  gland  at  the 
flexure  of  the  elbow  will  be  found  in  a  similar  condition  (Lymphadenitis).  If 
the  infection  be  not  of  too  virulent  a  character,  the  process  may  end  here,  pro- 


DISE  IS]  -    OF    WOUNDS 

vi'lnl  appropriate  local  treatmenl   Is  pursued.     The  lymph  nodee   usually  re- 
main enlarged  for  some  time  after  the  acute  process  has  <■<  osed.     In  other  c 
the  constitutional   Bymptoms   will   continue,   the   lymphatic  glands   will 

larger  and  •<•  tender;  purulenl  softening  of  the  glands  will  take  place.     Il' 

tin-  process  goes  as  far  as  this,  the  capsule  of  the  lymphatic  glands  will  usually 
be  perforated,  and  periglandular  infection  will  occur,  resulting  in  a  more  or 
less  extensive  abscess  of  the  axilla. 

Such  abscesses  are  usually  not  hard  to  recognize.  The  axilla  is  painful; 
motions  of  the  arm  are  restricted;  palpation  of  the  axilla  will  show  the  Bigns 
of  localized  purulenl  infection.  The  axilla  will  be  occupied  by  a  tender,  hard, 
circumscribed  or  diffuse  swelling.  The  skiu  will  be  reddened  if  the  al 
has  approached  the  3urface;  otherwise,  not  It'  the  abscess  is  deeply  seated 
the  elastic  feeling  imparted  to  the  examining  fingers  by  collections  of  fluid 
will  often  be  obscured  by  the  dense  inflammatory  infiltration  of  the  surround- 
ing structures.  If  the  ab-eess  has  approached  the  surface,  fluctuation  may  be 
detected.  The  constitutional  symptoms  will  become  more  severe  when  Buch  an 
abscess  forms,  to  be  followed  by  rapid  improvement  after  suitable  incision  for 
relief  of  ten-ion.  and  drainage. 

Signs  and  Symptoms  of  True  Septicemia. — Very  different  are  the  Bigns  and 
Bymptoms  of  true  septicemia;  happily,  we  rarely  Bee  at  present  grave  forms  of 
the  disease  follow  our  operative  procedures  upon  noninfected  tissues.  As  al- 
ready described,  some  of  the  mosl  rapidly  fatal  forms  of  the  disease  follow 
insignificant,  accidental  wounds.  Criminal  operations  upon  the  contents  of 
the  pregnant  uterus  are  not  infrequently  followed  by  forms  of  fatal  septicemia 
of  extreme  violence.  So,  also,  diseases  and  injuries  of  the  abdominal  viscera 
attended  by  the  sudden  pouring  out  into  the  peritoneal  cavity  of  a  large  quan- 
tity of  intensely  septic  material.  Accidental  wounds  of  large  joints  are  the 
starting-point  of  many  severe  cases. 

Septicemia  and  Acute  Emphysematous  Gangrene  Produced  by  the  Bacillus 
aerogenes  capsulatus. — The  Bacillus  aerogenes  capsulatus,  first  studied  by  Welch 
and  Flexner,  which  is  responsible  for  some  of  the  most  rapidly  fatal  cases,  is 
an  anaerobic  bacillus.  The  individual  rods  measure  from  3  to  6  p  in  length 
and  from  0.5  to  1  /*  in  breadth.  The  ends  of  the  rod  are  square  or  rounded. 
The  bacillus  occurs  singly,  in  pairs,  sometimes  in  chain-  or  threads.  Cultures 
are  only  possible  under  anaerobic  conditions.  The  colonies  arc  gray  or  brown- 
ish-white in  color;  when  viewed  by  transmitted  light  they  exhibit  a  central 
darker  spot.  Each  colony  measures  from  2  to  3  mm.  across.  Peep  colonies 
are  oval  or  spherical  in  shape,  with  featherlike  projections.  The  tissues  and 
the  blood  in  the  vessels  of  rabbits  killed  immediately  after  the  intravenous 
injection  of  a  suspension  of  the  germs  in  bouillon,  and  kept  foT  some  hours 
a  temperature  of  1"  < '..  contain  much  gas  and  numerous  bacilli.  As  orig- 
inally observed  and  studied  by  Welch,  the  germ  and  its  associated  gas  produc- 
tion was  only  found  at  autopsy  in  human  beings,  and  was  believed  to  be  non- 
pathogenic for  man.     During  the  pasl  few  years,  however,  a  number  of  observa- 


96        DISEASES    CAUSED   BY   THE   PUS-PRODUCING   BACTERIA 

tions  have  been  made  showing  that  the  bacilli  are  capable  of  producing  a  most 
intense  septicemia,  characterized  by  a  rapid,  fatal  course,  by  jaundice,  by  the 
production  of  gas  in  the  blood-vessels  and  in  the  tissues  throughout  the  body, 
and  by  the  parenchymatous  degeneration  of  the  parenchyma  of  organs  and  of 
muscle  fibers.  In  addition,  the  bacillus  has  been  demonstrated  as  a  gas  pro- 
ducer in  pneumothorax  and  pyopneumothorax,  in  peritonitis,  and  as  an  in- 
habitant of  the  bladder  in  pneumaturia.  Further,  it  is  observed  as  a  cause 
of  some  cases  of  acute  emphysematous  spreading  gangrene  with  putrid  decom- 
position. A  bacillus  believed  to  be  identical  can  often  be  demonstrated  in  the 
contents  of  the  intestine  in  normal  cases.  It  was  present,  apparently  in  pure 
culture,  in  two  fatal  cases  of  puerperal  septicemia  recently  observed  in  the  JSTew 
York  Hospital.  In  one  of  these  emphysematous  crackling  of  the  subcutaneous 
tissues  of  the  abdominal  wall  was  noted  before  death.  In  the  other,  the  char- 
acteristic appearances  were  only  observed  at  autopsy.  Both  of  these  cases  were 
characterized  by  an  extraordinary  virulence  and  rapidity  of  the  infectious 
process.  In  one,  death  is  believed  to  have  occurred  in  less  than  twenty-four 
hours  from  the  moment  of  infection;  in  the  other,  in  two  or  three  days.  The 
following  are  short  abstracts  of  the  histories  of  these  two  cases: 

Case  I.  Puerperal  Septicemia  from  Infection  with  Bacillus  aerogenes  capsu- 
latus. — A.  0.,  female,  aged  twenty-four,  was  brought  to  the  hospital  in  the  ambu- 
lance, at  ten  minutes  past  eight  in  the  morning,  with  the  following  history:  On 
the  day  before  admission  an  instrument  had  been  introduced  into  the  uterus  for 
the  purpose  of  inducing  an  abortion.  A  few  hours  afterwards  she  was  seized  with 
a  severe  chill,  nausea  and  vomiting.  Repeated  chills  and  continued  vomiting  fol- 
lowed, and  the  patient  became  very  ill  indeed.  During  the  night  a  physician  was 
called  who  emptied  the  uterus,  bringing  away  a  three-months'  fetus  and  mem- 
branes. Becoming  alarmed  at  the  very  serious  condition  of  the  patient,  an  ambu- 
lance was  sent  for,  and  arrived  about  an  hour  after  the  completion  of  the  opera- 
tion. On  the  arrival  of  the  ambulance  surgeon,  the  patient  was  conscious.  The 
expression  of  the  face  was  anxious;  pulse  was  rapid  and  weak;  slightly  jaundiced. 
There  was  slight  bleeding  from  the  uterus,  but  no  history  of  any  considerable 
hemorrhage.  During  the  journey  to  the  hospital,  which  consumed  ten  minutes, 
the  patient  became  unconscious.  The  jaundice  was  more  marked.  Upon  arrival 
at  the  hospital,  patient  was  unconscious;  deeply  jaundiced;  respiration  stertorous; 
no  perceptible  radial  pulse ;  temperature  upon  admission  101.2°  P. ;  respiration,  -10. 
In  twenty  minutes  the  patient  was  dead.  Autopsy  was  three  hours  later:  rigor 
mortis  slight;  general  jaundice;  general,  but  slight,  emphysema  of  the  subcutane- 
ous cellular  tissues;  gas  in  the  superficial  veins  of  the  arms.  The  peritoneal  cavity 
contained  a  little  gas  and  a  small  amount  of  bloody  fluid;  bloody  fluid  in  the 
pleural  cavities  and  pericardium.  Heart  cavities  contained  gas.  Spleen  was  some- 
what enlarged  and  soft;  tissue  blood-stained,  containing  a  little  gas;  liver  and 
kidneys  blood-stained;  blood  contained  a  little  gas;  uterus  enlarged  and  contained 
a  blood  clot.  The  peritoneal  coat  over  the  posterior  surface  of  the  uterus  was 
ruptured  in  several  places  from  the  accumulation  of  gas  beneath  it.  Microscopic 
examination  of  the  tissues  showed  parenchymatous  degeneration  of  all  the  tissues 


DISEASES    OF    WOUNDS  97 

examined.  Kidneys  were  aecrotic.  Bacillus  aerogenes  capsulatus  was  identified  in 
the  blood  by  microscopic  examination  and  cultures. 

Case  II.  M.  I'.,  female,  aged  twenty-six,  was  admitted  to  the  hospital  ;it  noon, 
with  the  following  history:  Two  days  before  admission  a  metal  instrumenl  had 
been  introduced  im<>  the  uterus  for  the  purpose  of  bringing  on  an  abortion.  The 
operation  was  followed  in  a  few  hours  by  Bevere  chills,  fever,  nausea  and  vomiting. 
A  physician  was  called  who  advised  hospital  treatmenl  immediately.  On  admission 
the  patient  looked  profoundly  septic:  slight  jaundice  of  -kin  and  conjunctiva; 
temperature,  104.8°  F. :  pulse,  132;  respiration,  <i  I  :  heart  and  Lungs  negative;  abdo- 
men— liver  dullness  normal,  no  abdominal  distention,  marked  general  abdominal 
rigidity  and  tenderness;  vagina]  examination — cervix  Boft,  admits  one  finger,  body 
of  uterus  three  times  the  normal  size  and  -oft.  bloody  discharge  containing  shreds 
of  tissue  from  the  cervix;  active  stimulation.  Patient  was  taken  to  the  operating 
room  for  operation  two  hours  after  admission.  Palpation  of  the  abdomen  showed 
emphysematous  crackling  in  the  subcutaneous  tissues  of  the  abdominal  wall.  Pal- 
pation and  percussion  showed  the  spleen  much  increased  in  size.  The  patient  began 
to  fail  so  rapidly  that  no  operation  was  attempted.  The  patient  was  put  to  bed 
at  once,  where  she  died  in  a  few  moments.  Autopsy,  twenty-three  hours  later,  was 
as  follows:  moderate  rigor  mortis;  general  jaundice;  emphysema  of  cellular  tissues 
throughout  (lie  body  well  marked;  the  pleura,  the  pericardium,  the  peritoneum 
contained  gas  and  bloody  fluid;  the  gas  burned  with  a  blue  flame;  300  c.c.  of 
fluid  in  the  peritoneum;  all  the  tis-ues  infiltrated  with  blood  pigment;  spleen  five 
times  its  normal  size;  capsule  dissected  off  the  parenchyma  by  accumulated  gas; 
substance  of  the  spleen  contained  much  gas;  uterus — the  veins  of  the  uterus  con- 
tained thrombi;  bladder  contained  bloody  urine.  Microscopic  examination  showed 
parenchymatous  degeneration  of  all  the  tissues.  Bacillus  aerogenes  capsulatus  dem- 
onstrated as  in  the  former  case. 

The  noteworthy  characters  of  the  disease  in  this  case  wore  the  slowly  pro- 
gressive symptoms  of  septic  poisoning,  which  proceeded  until  death,  entirely 
uninfluenced  by  local  treatment.  It  is  to  be  noted  that  the  leucocytosis  never 
rose  very  high  in  spite  of  the  severity  of  the  septic  poisoning,  the  percentage 
of  polynuclears  being  always  high  after  the  first  W'W  days;  in  other  words,  the 

hi I  and  other  tissues  reacted  hut  feebly  and  inefficiently  to  stay  the  progress 

of  the  infection.  Blood  cultures,  although  often  made,  only  disclosed  the 
presence  of  hacteria   shortly  before  death. 

Cases  of  emphysematous  gangrene  caused  by  Bacillus  aerogenes  capsulatus 
have  been  reported  by  G.  E.  Brewer,  John  B.  Roberts  (Annals  of  Surgery, 
dune,  L901),  and  others.  Brewer's  case  was  that  of  a  woman  who  had  had  a 
pain  in  the  ischiorectal  region  for  a  week  before  coming  to  the  hospital  for 
treatment;  during  this  time  she  had  fell  ill  and  prostrated.  On  admission 
there  were  general  symptoms  of  sepsis.     Locally  there  was  marked  swelling  of 

the  vulva  and  ischiorectal  space  upon  the  left  side.  There  was  a  superficial 
area  of  gangrene  on  the  left  labium  majus.  Encision  revealed  a  condition  of 
emphysematous  gangrene  n\'  the  subcutaneous  tissue  of  the  ischiorectal   fossa 

and   labium,    including  a   very    large  area   of   the    left    Bide  of  the   wall   of  the 


98        DISEASES    CAUSED   BY   THE   PUS-PRODUCING   BACTERIA 

belly.  Recovery  took  place  after  extensive  incisions  and  the  separation  of 
much  necrotic  tissue.  Bacillus  aerogenes  capsulatus  was  identified  in  pure 
culture  and  by  animal  inoculation  in  the  putrid  fluid  escaping  from  the  wound 
at  the  time  of  operation  and  from  the  necrotic  tissues. 

Dr.  Roberts's  case  was  that  of  a  young  girl,  aged  twelve  years,  who  in 
falling  sustained  a  fracture  of  the  shafts  of  the  radius  and  ulna,  with  a  very 
small  wound  in  the  skin  created  from  within  by  the  broken  ulna.  Three  days 
later  the  patient  was  seen  by  Dr.  Roberts,  who  found  emphysematous  gangrene 
of  the  forearm.  The  following  day  amputation  was  done  through  the  middle 
of  the  upper  arm ;  gangrene  of  the  stump  followed,  but  was  controlled  without 
further  amputation.  Recovery  took  place.  The  tissues  and  blood-vessels  of 
the  amputated  limb,  arteries,  and  veins  contained  gas.  Pure  cultures  of  Bacil- 
lus aerogenes  capsulatus  were  obtained  from  tissues  and  fluids  of  amputated 
limb.  In  this  case  there  were  marked  septic  symptoms  and  the  signs  of  acute 
nephritis. 

A  more  common  type  of  septicemia  complicated  by  pyemic  chills  is  well 
illustrated  by  the  following  case,  in  which  the  disease  ran  a  rather  chronic 
course.  The  difference  between  septic  intoxication  and  septicemia  is  well 
shown.  The  removal  of  the  local  lesion  did  not  affect  the  progress  of  the 
disease,  nor  avert  a  fatal  issue. 

Case  III.  Subacute  Septicemia  and  Pyemia  Following  Infection  of  the  Knee- 
joint  Secondary  to  Compound  Fracture  of  the  Patella  from  Direct  Violence,  with 
Death  Sixty-three  Days  after  the  Accident. — L.  Y.,  a  vigorous  young  Italian, 
aged  twenty-four,  was  hurt  by  a  piece  of  flying  iron  propelled  by  the  accidental 
explosion  of  a  quantity  of  gunpowder.  He  was  brought  to  the  hospital  at  once 
by  ambulance.  His  injury  was  found  to  be  a  compound  fracture  of  the  left  patella, 
with  notable  contusion  and  laceration  of  the  overlying  soft  parts.  Immediate 
careful  disinfection  of  wound,  suture  of  patella,  bilateral  drainage  of  knee-joint 
were  made.  On  the  third  day  redness  of  wound  edges  was  noted ;  sutures  removed. 
On  the  fifth  clay  there  was  severe  pain  in  knee;  irrigation  of  joint  with  salt  solu- 
tion; leucocyte  count  10,000,  seventy  per  cent  potynuclears ;  rise  of  temperature 
to  101.5°  F. ;  pulse,  92.  The  seventh  day  there  was  a  rise  of  temperature  to  104° 
F. ;  discharge  from  knee  distinctly  purulent;  cultures  showed  pure  Streptococcus 
pyogenes  infection;  incision  and  drainage  of  quadriceps  bursa.  From  this  time  on 
the  local  and  general  conditions  grew  slowly  worse.  The  knee  continued  to  discharge 
pus,  and  the  periarticular  structures  were  gradually  invaded  by  purulent  inflamma- 
tion in  spite  of  repeated  free  incisions  for  adequate  drainage.  The  temperature  curve 
became  of  a  distinctly  septic  type ;  irregular  rises  up  to  I04°-105°  F.  occurred,  fol- 
lowed by  a  slow  or  rapid  fall  to  100°  to  99°  F.  The  pulse  rate  corresponded  for  the 
most  part  with  the  temperature,  but  as  the  weeks  went  by  the  pulse  gradually  became 
more  rapid ;  the  patient  had  no  desire  for  food ;  he  became  weaker,  pale,  anemic,  and 
emaciated.  At  the  end  of  a  month  from  the  time  of  the  injury  his  hemoglobin 
had  fallen  to  thirty-eight  per  cent.  At  no  time  during  his  illness,  until  within 
two  days  of  his  death,  was  there  any  marked  leucocytosis.  The  highest  number 
of  leucocytes  recorded  during  this  period  was  on  the  thirty-eighth  day;  it  was  then 


DISEASES    OF    WOUNDS 

16,000  with  eighty  per  cent  of  polynuclears.     For  the  mosl  part  it  varied  between 
9,000  ami   12,000.     Blood  cultures  were  made  from  time  to  time,  and  were  always 
negative  until  two  days  before  death,  when  the  l»l I  was  found  to  contain  numer- 
ous Btreptococci.     <m  the  thirtieth  day  of  his  illness  Bacillus  pyocyaneus  wai 
served  in  the  discharge  from  the  knee,  in  addition  to  the  streptococcus. 

On  the  thirty-second  day  amputation  of  the  thigh  was  made.  All  the  soft  part- 
below  the  middle  of  the  thigh  were  found  riddled  with  purulent  foci.  The  struc- 
tures entering  into  the  knee-joint  were  practically  destroyed  by  purulent  softening. 
No  improvement  in  either  the  local  or  general  conditions  followed  the  amputation. 
The  amputation  siump  began  at  once  to  suppurate.  Up  to  this  time  the  patient 
had  had  no  chills.  Four  days  after  the  amputation  the  patient  had  a  severe  chill 
and  a  rise  of  temperature  to  100°  F.  From  this  time  until  death  irregular  chills 
occurred,  sometimes  daily,  sometimes  every  second  day.  with  gradually  increasing 
frequency,  until  a  week  before  lie  died,  when  the  chills  ceased.  After  the  ampu- 
tation was  done  the  patient's  pulse  was  never  less  than  L05  or  Hit  heats  per 
minute,  and  rose  to  1  l<>  or  1"><>  during  the  upward  excursions  of  the  temperature. 
During  the  daytime  he  was  apathetic  and  delirious  at  night.  lie  became  greatly 
emaciated  and  profoundly  anemic.  A  large  bedsore  formed  over  the  sacrum.  A 
septic  diarrhea  developed.  During  the  last  week  of  his  life  the  temperature  curve 
was  more  continuous  and  not  so  high,  varying  between  I11'-'  ami  103  F.  He 
developed  incontinence  of  urine  and  feces,  and  died  unconscious,  of  exhaustion 
si\tv-three  days  after  the  injury.  No  autopsy  could  he  obtained,  but  during  life 
there  were  no  signs  of  metastatic  abscesses.  During  the  last  three  weeks  of  his 
life  his  urine  indicated  the  presence  of  acute  nephritis. 

Gangrenous  Appendicitis — Septic  Thrombophlebitis  of  the  Mesenteric  Veins — 
Septic  Inflammation  of  the  Portal  Vein  and  Secondary  Abscesses  in  the  Liver. — 
This  is  a  true  pyemia,  which  differs  from  ordinary  pyemia  only  in  that  the 
secondary  septic  foci  occur  in  and  are  usually  confined  to  the  liver.  The  con- 
dition is  one  which  may  follow  any  case  of  gangrenous  appendicitis.  Some- 
times its  occurrence  may  be  predicted  with  probability  when  at  the  time  of  the 
operation  we  find  not  only  the  appendix,  but  also  its  mesenteriolum,  totally 
gangrenous.  It  is  sometimes  possible  in  these  cases  to  observe  that  the  veins 
still  further  above  are  filled  with  infected  thrombi.  The  condition  is,  in  my 
experience,  invariably  fatal.  In  some  cases,  as  in  the  one  about  to  be  de- 
scribed, the  disease  runs  a  stormy  course  from  the  start;  in  others  the  spread 
of  the  septic  thrombi  in  the  veins  is  slow  and  insidious.  Sometimes  these 
patients  seem  to  be  doing  very  well  indeed:  at  the  end  ><{  a  week  or  ten  day- 
following  the  operation  there  will  be  no  evidence  of  peritoneal  irritation.  The 
temperature  may  remain  but  slightly,  or  not  at  all,  elevated  during  the  twenty- 
four  hours.  The  abdominal  wound  may  heal.  The  pulse,  however,  does  not 
return  to  normal,  but  remains  accelerated.  The  abdomen  may  remain  tlat  and 
i'vi'r  from  tenderness,  or  in  some  eases  there  may  be  an  accumulation  >>(  a 
small  amount  of  serous  fluid  in  the  abdominal  cavity;  but  instead  of  getting 
well,  these  patients  continue  to  look  ill.  They  are  nol  able  to  cat  well.  They 
become  markedly   anemic.      The   skin   is  often   a    little   jaundiced.      The   liver 


100      DISEASES    CAUSED   BY   THE   PUS-PRODUCING   BACTERIA 

may  remain  normal  in  size,  or  may  project  to  a  moderate  extent  below  the 
free  border  of  the  ribs.  After  two  or  three  weeks  these  patients  will  complain 
of  a  little  pain  and  tenderness  over  the  right  lobe  of  the  liver.  If  aspirating 
needles  are  thrust  into  the  substance  of  the  liver,  it  is  usually  possible,  after 
repeated  trials,  to  withdraw  a  little  pus  containing  shreds  of  broken-down  liver 
tissue.  In  some  cases  disseminated  abscesses  of  considerable  size  will  be  formed 
in  the  liver  substance ;  in  some,  subphrenic  abscess  may  develop ;  in  others,  the 
patient  will  become  dull  and  apathetic,  and  become  weaker  and  weaker,  and 
finally  die  of  exhaustion  due  to  septic  absorption  and  to  disturbances  in  the 
function  of  the  liver;  and  at  the  autopsy  the  branches  of  the  portal  vein  in 
the  liver  will  be  found  filled  with  septic  thrombi,  and  surrounded  by  areas 
of  purulent  softening  and  necrosis  of  liver  tissue.  Empyema  by  extension 
through  the  diaphragm  or  subphrenic  abscess  may  complicate  the  condition. 
Recent  observations  indicate  that  septic  inflammation  of  the  mesenteric  and 
portal  veins  with  liver  pyemia,  or  more  rarely  with  the  production  of  one 
or  more  large  abscesses  in  the  liver,  may  appear  long  after  an  attack  of  appen- 
dicitis appears  to  be  cured,  or  may  follow  weeks  or  even  months  after  an 
operation  for  gangrenous  appendicitis;  and  further,  that  it  is  quite  probable 
that  septic  abscesses  in  the  liver  occurring  without  apparent  cause  may  be 
due  to  infection  through  a  minute  ulceration  in  the  mucous  membrane  of  the 
appendix  so  small  as  never  to  have  been  recognized  by  its  symptoms. 

The  following  case  illustrates  a  gangrenous  appendicitis  complicated  by 
septic  thrombophlebitis  of  the  portal  vein  and  typical  symptoms  of  an  acute 
pyemia,  with  death  from  exhaustion  on  the  twenty-fourth  day: 

S.  N.,  forty-two  years  of  age,  a  man  of  large,  fine  physique  and  of  exemplary 
habits,  was  admitted  to  the  hospital  with  the  following  history:  The  day  before 
admission  he  had  been  suddenly  seized  with  the  symptoms  of  acute  appendicitis. 
Twenty-four  hours  after  the  beginning  of  the  attack  his  temperature  was  99°  F.  and 
his  pulse  80.  He  had  a  leucocyte  count  of  15,000  with  ninety-three  per  cent  of 
polymorphonuclear  cells.  The  local  signs  and  symptoms  of  acute  appendicitis  were 
well  marked.  Upon  opening  the  abdomen,  a  very  little  clear  fluid  escaped.  The 
appendix  was  large,  situated  close  to  the  anterior  abdominal  wall;  the  entire 
appendix,  including  its  mesenteriolum,  was  gangrenous.  There  were  some  slight 
adhesions  around  the  appendix;  upon  separating  these  a  small  abscess  was  opened 
containing  about  two  drachms  of  very  foul-smelling,  dirty,  greenish-brown  pus.  Re- 
moval of  gangrenous  appendix  with  its  mesentery  was  made;  cleaning  of  the  struc- 
tures in  the  vicinity;  drainage  with  a  large  gauze  wick  wrapped  in  rubber  tissue; 
abdominal  wound  left  largely  open.  The  patient's  temperature  rose  at  once  to 
105°  F.,  with  a  corresponding  acceleration  of  pulse  rate.  Exploration  of  the  wound 
upon  the  following  day  showed  the  entire  wound  surface  as  far  as  the  skin  gan- 
grenous. All  sutures  were  removed;  wound  washed  with  peroxide  and  salt.  A 
little  thin,  greenish,  foul  pus  escaped  upon  withdrawing  the  drain,  but  there  was 
no  evidence  of  an  extension  of  the  process  in  the  peritoneal  cavity.  Upon  the  third 
day  the  patient  had  a  chill  and  a  rise  of  temperature  to  106°  F.,  and  for  the  first 
time  he  began  to  look  and  feel  severely  ill.     These  chills  and  corresponding  rises 


DISEASES   OF   WOUNDS  nil 

of  temperature  recurred  daily,  or  ever)  other  day,  until  the  end  of  two  weeks,  when 
they  ceased.  They  were  followed  by  profuse  Bweats,  marked  prostration,  and  a 
sudden  fall  of  temperature  of  five  or  six  degrees.  During  all  this  time  the  patient's 
pulse  remained  of  fair  quality,  bul  always  a  little  more  accelerated  from  day  to 
day.  The  patient  did  qo1  complain  of  abdominal  pain;  he  continued  to  take  a 
Bufficienl  quantity  of  rood;  he  had  no  diarrhea.  On  several  occasions  he  was  put 
under  the  influence  of  chloroform  and  the  peritoneal  cavity  carefully  explored  for 
secondary  foci  of  inflammation;  none  were  found.     In  the  mean  time  the  condition 

of  the  abd inal  wound   had  so  far  improved  thai   all  appearance  of  necrotic  or 

gangrenous  inflammation  had  disappeared.  The  wound  surfaces  became  clean, 
and  the  coils  of  intestine  at  the  bottom  of  the  wound  looked  smooth  and  fairly 
healthy.  Only  a  little  thin,  purulent  discharge  could  be  removed  from  the  site  of 
the  base  of  the  appendix  at  the  daily  dressing. 

It  was  noticeable,  however,  that  no  effort  whatever  was  being  made  by  the  tis- 
sues toward  healing;  no  granulations  wen-  formed;  the  wound  edges  remained  pale, 
and  did  not  bleed  upon  manipulation.  The  general  condition  of  the  patient  grew 
steadily  worse,  lie  began  to  be  xevy  pale;  his  face  had  an  anxious  expression; 
dark  hollows  formed  beneath  bis  vyv^ :  his  tongue  was  coated;  his  forehead  was 
often  bathed  in  a  clammy  sweat.  Following  the  chills  Ins  physical  and  mental 
distress  were  pitiable.  At  the  end  of  two  weeks  the  condition  of  bis  abdominal 
wound  remained  unchanged,  except  that  the  amount  of  the  discharge  was  reduced 
to  a  very  little,  and  that  of  a  serous  character.  His  mind  wandered  a  little  in  the 
daytime;  at  night  be  was  distinctly  delirious.  He  no  longer  took  bis  food  well, 
and  bad  to  lie  urged  to  swallow  it.  The  degree  and  character  of  the  leucocytosis 
continued  about  the  same.  Blood  cultures  were  negative.  Upon  the  sixteenth  day 
lie  began  to  complain  of  pain  and  tenderness  over  the  right  lobe  of  the  liver.  The 
liver  percussed  a  little  large.  On  the  eighteenth  day  an  aspirating  needle  thrust  into 
the  substance  of  the  liver  withdrew  from  various  situations  a  few  drops  of  brown- 
ish material,  found  under  the  microscope  to  consist  of  necrotic  liver  tissue  and  of 
pus.  Xo  more  chills  occurred  after  the  fifteenth  day.  The  temperature  curve 
assumed  a  more  continuous  type,  and  varied  from  102°  to  105°  F..  with  a  steadily 
increasing  acceleration  of  pulse  rate.  He  became  a  little  jaundiced.  His  mental 
condition  became  more  and  more  confused  and  dull.  He  suffered  from  dyspnea. 
The  physical  signs  of  bronchitis,  merely,  were  present  in  the  chest.  Slowly,  hut 
steadily,  the  symptoms  of  exhaustion  ensued,  and  be  died  on  the  twenty-fourth 
day  of  the  disease.  An  autopsy  was  not  permitted.  He  did  not  develop  a  septic 
diarrhea,  nor  were  the  signs  and  symptoms  of  nephritis  present. 

Special  Groups  of  Symptoms  in  Septic  Infections. — In  cases  of  septic  infec- 
tion certain  signs  and  symptoms  are  present  indicating  disturbances  of  certain 

organs  or  groups  of  organs.  They  arc  not  peculiar  to  these  (Anns  id'  infection, 
but  vol  form  an  essential  part,  of  the  clinical  picture.  We  have  already  indi- 
cated the  disturbances  of  the  heart  and  the  temperature,  and  may  now  con- 
sider the  disturbances  of  the  alimentary  canal. 

Alimentary  Canal. — The  appetite  is  usually  diminished  or  lost  The 
power  <d'  digesting  food  is  more  or  less  seriously  impaired,  according  to  the 
intensity  of  the  poison.      In  nearly  all  cases  of  severe  septic  intoxication,  except 


102      DISEASES    CAUSED    BY    THE    PUS-PKODUCIXG    BACTEEIA 

those  which  involve  an  inflammation  of  the  peritoneum  or  an  obstruction  to 
the  alimentary  canal,  diarrhea  is  present  at  some  time  during  the  disease;  if 
severe,  and  uncontrollable  by  careful  regulation  of  the  diet,  it  is  a  symptom 
of  serious  import.  The  stools  are  often  very  offensive.  The  catarrhal  con- 
dition of  the  intestine  may  he  accompanied  by  ecchymoses  into  the  mucous 
membrane  and  by  hemorrhages.  Ulcers  resembling  those  of  dysentery  may 
occur.  Many  cases  of  septic  intoxication  are  accompanied  by  vomiting.  The 
vomiting  may  occur  during  the  onset  of  the  disease,  as  is  so  commonly  the 
case  with  acute  inflammations  of  the  peritoneum,  or  it  may  develop  later  when 
the  vital  powers  of  the  patient  are  greatly  depressed,  and  is  then  of  unfavor- 
able import. 

Nervous  System. — The  nervous  system  is  always  more  or  less  profoundly 
affected.  Many  cases  of  severe  septic  intoxication  are  ushered  in  by  a  chill. 
Headache  is  commonly  present  when  the  temperature  is  elevated  above  102° 
or  103°  F.  In  more  severe  cases  the  headache  in  the  daytime  alternates  with 
delirium  at  night.  In  fatal  cases  stupor  and  coma  follow  the  delirium,  and 
persist  until  death. 

Heart  axd  Lungs. — Pericarditis  and  pleurisy,  either  sero-flbrinous  or 
purulent,  are  occasional  complications,  and  give  rise  to  characteristic  signs 
and  symptoms. 

Broncliitis  and  pneumonia,  usually  of  the  lobular  variety,  are  fairly  com- 
mon complications,  and  are  to  be  recognized  by  the  cough,  expectoration,  and 
the  physical  signs. 

Kidneys. — The  function  of  the  kidneys  is  disturbed.  The  quantity  of 
urine  is  diminished ;  the  urine  is  of  a  high  specific  gravity  and  dark  in  color. 
In  severe  cases  an  acute  exudative  nephritis  may  develop,  with  the  presence  of 
albumin  in  the  urine,  together  with  casts  containing  blood  cells.  In  some  cases 
a  true  hemorrhagic  nephritis  occurs,  with  more  than  a  microscopic  amount  of 
blood  in  the  urine.  The  urine  may  contain  numerous  living  pyogenic  microbes. 
In  fatal  cases  cloudy  swelling  or  parenchymatous  degeneration  of  the  renal 
epithelium  is  present — most  marked  in  the  glomeruli.  In  very  chronic  cases 
waxy  or  amyloid  degeneration  of  the  kidney  may  occur.  The  capillaries  of 
the  glomeruli  may  contain  numerous  bacteria. 

Spleex,  Liver,  and  Skix. — The  spleen  is  usually  enlarged  in  septicemia, 
and  after  death  may  be  softened  and  show  the  lesions  of  parenchymatous  de- 
generation. The  liver  is  often  enlarged,  and  in  a  similar  condition  of  degen- 
eration. The  jaundice  which  sometimes  accompanies  severe  forms  of  septi- 
cemia is  due  to  disintegration  of  the  red  blood  cells  and  liberation  of  the 
pigment.  Various  shin  lesions  may  accompany  septicemia  ;  urticaria,  erythema, 
papules,  pustules,  and  blebs  are  not  infrequent.  Sometimes  the  skin  eruptions 
may  resemble  those  of  scarlet  fever  or  measles.  During  the  earlier  stages  of 
septic  fever,  sweating  is  often  a  marked  symptom,  especially  after  a  sudden 
fall  of  temperature ;  the  sweat  sometimes  has  a  sour  odor.  If  the  disease 
exists  for  some  time,  the  skin  becomes  harsh,  dry,  and  scaly. 


DISEASES    OF    W'olNDS 


[03 


The  Blood  in  Septic  Processes. — The  rc<l  blood  cells  are  rapidly  destroyed  in 
all  generalized  septic  processes  septicemia  and  pyemia.  The  anemia  con 
liniirs  to  increase  as  long  as  the  infection  endures,  and  may  reach  a  profound 
decree  in  ;i  shorl  time.     Nol  only  the  number  of  red  cells  i-  diminished,  but 

« 

iilso  the  percentage  of  hemoglobin.  It.  has  been  noted,  for  example,  in  many 
instances,  thai  the  number  of  red  cells  were  reduced  to  2,000,000  and  even 
lower,  ami  the  hemoglobin  may  be  diminished  to  thirty,  or  even  twenty  per 
cent.  This  rapid  blood  change  is  far  less  marked  in  localized  suppurative 
affections  where  the  degree  of  intoxication  is  no1  marked,  and  where  no  gen 
era!  invasion  of  the  organism  by  }>ns  microbes  has  taken  place.  Nucleated  red 
cells  arc  occasionally  observed  in  septic  processes.  hut  qoI  in  large  numbers. 

Chronic  suppuration  induces  anemia,  with  diminution  of  red  cells  and  of 
hemoglobin.  For  example,  in  a  case  of  suppurating  sinuses  of  the  thigh  leading 
to  dead  bone,  which  had  existed  for  three  years,  I.  found  the  red  cells  dimin- 
ished t<>  2,300,000,  and  hemoglobin  to  thirty  per  cent.  Suppuration  had  been 
fairly  active  during  this  period.  If  the  amount  of  suppuration  be  small,  the 
Mood  changes  are  nol  marked.  Changes  in  the  shape  and  diameter  of  red 
blood  cells  are  sometimes  seen  in  severe  septic  processes  which  have  existed  for 
some  time.  The  red  cells  are  diminished  in  diameter,  and  may  show  granular 
degeneration. 

Leucocytosis. — Suppurative  processes  arc  usually  accompanied  by  an  in- 
creased number  of  leucocytes  in  the  blood.     Leucocytosis  is  sometimes  absenl   in 


Approximate  Differential  Count  of  Leucocytes  in — 

Normal 
Blood. 

Chlorosis. 

Second- 
ary 
Anemia. 

Perni 
cious 

Anemia. 

Acute 
Lym- 
phatic 
Leuke- 
mia. 

Chronic 
I.\  in 
phatic 

Leuke- 
mia. 

Myeloid 
Leuke 

niia. 

Inflain 
matory 
Leucocy- 

losis. 

Small  Lymphocyte 

Polynucl.  Neutrophil . . . 
Eosinophils 

28* 

85* 

38* 

42* 

V 

88 

8* 

6* 

6 

6* 

4* 

90* 

1 

5* 

3* 

6*-l* 

65* 

58* 

5.V. 

50* 

J 

30* 

65*-95* 

H 

I 

1* 

3* 

0.5* 

0.2 

6* 

1 
0.2 

Bnsophile 

O.'V 

0.2* 

0.2* 

0.0 

None 

None 

0.2* 

Eosinoph.  Myelocyte  .... 

None 

None 

None 

1* 

2* 

None 

45* 

Nolle 

None 

None 

Nolle 

None 

None 

Nolle 

8* 

None 

A  purulent  process  increases  the  percentage  <>(  polynuclear  cells  in  inflammatory  leucocytosis. 
Fig.  22. — Sdndkhx's  Tahi.i:  of   Difif.rentiax   Leucocyt]    CotTNTS. 


asthenic  types  of  septicemia;  the  number  of  leucocytes  in  the  blood  may  be 
subnormal.  Local  suppurative  processes  are  commonly  attended  by  a  leuco- 
cytosis whose  grade  is  in  proportion  to  the  intensity  of  the  inflammation  and 
to  the  reaction  of  the  organism  againsl  the  invasion  of  the  pus-producing  germs. 
Purulent  collections  of  small  size,  if  under  nuich  ten-ion,  are  often  accom- 
panied by  a  high  leucocyte  count.     Tin'  leucocytosis  id'  local  processes  usually 


104      DISEASES    CAUSED   BY   THE   PUS-PKODUCING   BACTEEIA 

lasts  as  long  as  the  inflammatory  exudation  continues,  or  until  the  condition 
is  relieved  by  operation,  when  it  will  suddenly  or  gradually  decline.  Purulent 
inflammations  of  mucous  membrane  are  not  usually  attended  by  a  marked  in- 
crease in  the  number  of  leucocytes.  In  the  leucocytosis  of  purulent  inflamma- 
tion the  polynuclear  forms  of  white  cells  show  the  most  notable  increase. 

The  Diagnostic  Value  of  Leucocytosis. — This  varies  a  good  deal  in  different 
types  of  purulent  inflammation.  In  local  processes  a  steady  increase  in  the 
number  of  leucocytes  usually  indicates  a  spreading  of  the  lesion,  and  a  sudden 
increase  sometimes  indicates  that  new  areas  have  suddenly  become  infected, 
as,  for  example,  from  the  perforation  of  a  gangrenous  appendicitis  and  com- 
mencing peritonitis.  Absence  of  leucocytosis  does  not,  as  above  indicated, 
exclude  the  presence  of  septicemia,  and  leucocytosis  may  exist  in  a  large  num- 
ber of  pathological  conditions  other  than  suppurative  processes.  Hence,  the 
value  of  the  leucocyte  count  in  differentiating  between  obscure  foci  of  suppura- 
tion and  certain  other  conditions  may  be  great  or  small  in  the  individual  case. 
For  example,  acute  appendicitis,  attended  by  abscess,  gangrene,  or  purulent 
peritonitis,  is  almost  always  attended  by  marked  leucocytosis;  typhoid  fever, 
unaccompanied  by  suppurative  complications,  is  not.  It  may  occasionally 
happen  that  confusion  will  arise  in  the  early  stage  of  typhoid,  with  marked 
tenderness  in  the  right  iliac  fossa,  between  this  disease  and  appendicitis.  Ab- 
sence of  leucocytosis  enables  the  observer  to  exclude  appendicitis  of  the  above- 
mentioned  types ;  not,  however,  simple  catarrhal  appendicitis,  nor  yet  the  sud- 
den violent  cases  of  peritoneal  sepsis  from  perforation,  nor  the  asthenic  types 
of  the  disease,  for  in  the  two  latter  leucocytosis  may  be  absent. 

The  following  description  of  leucocytes  is  quoted  by  permission  from 
Ewing : 

The  Leucocytes  and  Leucocytosis. — Morphology  of  Leucocytes. — In  fresh 
blood  leucocytes  are  colorless,  rather  highly  refractive  bodies,  usually  larger 
than  red  cells,  cohering  to  one  another  and  to  the  glass,  and  exhibiting  a  highly 
refractive,  compact,  or,  in  the  large  mononuclear  cells,  vesicular  nucleus.  Gran- 
ules are  invisible  in  the  normal  mononuclear  cells  of  the  circulation,  but  in  the 
others  minute  opaque  (neutrophile)  granules  are  distinctly  apparent  in  the  poly- 
nuclear cells,  and  large  greenish  refractive  granules  serve  to  fully  distinguish 
the  eosinophile  cells.  The  protoplasm  of  the  mononuclear  cells  is  homogeneous, 
and  refractive  in  the  lymphocytes,  transparent  in  the  large  mononuclear.  Ame- 
boid motion  begins  promptly,  especially  on  a  warm  stage,  in  the  finely  and 
coarsely  granular  cells,  becomes  most  active  usually  after  twenty  to  forty  min- 
utes, and  may  persist  for  hours.  In  some  later  stages  of  ameboid  activity 
the  granules  may  show  extremely  active,  vibratory,  dancing,  and  swarming 
movements  in  cell  bodies  or  processes.  These  have  been  regarded  as  Brownian 
movements  or  as  indicating  structural  changes  of  approaching  death  of  the 
cell.  In  many  cells,  especially  in  anemic  blood,  there  appear  from  the  first 
large  and  small  clear  spheroidal  areas  which  on  staining  appear  to  be  divided 


DISEASES   OF    WOUNDS  105 

among  watery   vacuoles,  or  granules   of   fat,  glycogen,   or  oilier   degenerative 
products. 

Vabieties  of  Leucocytes.—  In  stained  specimens  five  varieties  of  leuco- 
cytes may  be  distinguished,  viz.: 

1.  Lymphocytes. 

2.  Large  mononuclear  leucocytes. 

3.  Polynuclear  neutrophile  leucocytes. 

4.  Eosinophile  leucocytes. 

5.  Mast-cells. 

1.  Lymphocytes  are  classed  as  (a)  small  and  |  6  )  large,  the  small  cells  being 
,r>  /i  to  <s  p-  in  diameter,  and  the  large  ones  S  /*  to  10  p.  Both  sizes  exhibit  a  nar- 
row rim  of  strongly  basophile  homogeneous  <>r  coarsely  reticulated  cytoplasm, 
and  compact  or  coarsely  reticulated  spheroidal  nuclei,  which  are  usually  less 
basophilic  than  the  cytoplasm.  With  ordinary  stains  these  cells  fail  to  show 
cytoplasmic  granules,  although  exhibiting  nodal  thickenings  of  the  cytoreticulum 
which  sometimes  resemble  granules.  After  the  Nocht-Romanowsky  stain  all 
lymphocytes  usually  show  a  variable  number  of  large  and  small  violet-stained, 
granules,  and  in  some  of  the  larger  cells  the  number  of  these  granules  ap- 
proaches that  of  the  myelocyte.  The  nuclei  of  lymphocytes  usually  contain 
nodal  thickenings  resembling  nucleoli.  While  the  nuclei  of  lymphocytes  are 
usually  spheroidal,  there  occur  in  normal  blood,  and  especially  in  lymphemia, 
medium-sized,  strongly  basophilic,  hyaline  leucocytes  with  incurved  or  sub- 
divided nuclei,  which  must  be  classed  with  lymphocytes. 

2.  Large  mononuclear  leucocytes  may  be  only  slightly  larger  than  lympho- 
cytes, but  many  of  them  are  the  largest  cells  seen  in  normal  blood.  Their  pro- 
toplasm is  slightly  basophilic  and  very  finely  reticular^  with  nodal  thickenings 
often  resembling  basic  granules,  while  other  cytoplasmic  granules  are  usually 
demonstrable  by  the  Nocht-Romanowsky  method.  Their  nuclei  are  vesicular, 
rather  coarsely  reticulated,  with  one  or  two  central  nodal  thickenings  resem- 
bling nucleoli,  but  no  true  nuclei  have  as  yet  been  demonstrated  in  these  cells. 
The  nuclei  may  be  circular,  or  horseshoe-shaped  (transitional  leucocytes),  or 
elongated.  In  Ehrlich's  triacid  solution  the  bodies  of  mononuclear  basophile 
cells  stain  very  faintly  red. 

3.  Poli/nuclcar  leucocytes  are  two  or  three  times  as  large  as  the  red  cell. 
Their  protoplasm  is  reticulated  and  possesses  as  integral  parts  <'\'  the  reticulum 
protoplasmic  neutrophile  granules  in  considerable  number.  The  reticulum  is 
otherwise  very  slightly  basophilic,  and  may  be  demonstrated,  with  basophilic 
nodal  thickenings  or  granules,  by  methylene  blue.  Their  nuclei  are  elongated 
and  constricted,  or  composed  of  two  or  move  lobes  usually  connected  by  threads 
of  chromatin.  These  lobes  are  coarsely  reticulated,  and  usually  possess  a 
central  nodal  thickening,  but  true  nucleoli  have  not  been  demonstrated.  The 
lobes  may  become  completely  separated    from  each  other. 


106      DISEASES    CAUSED   BY   THE   PUS-PEODUCING   BACTEEIA 

4.  Eosinophile  leucocytes  vary  in  size  from  that  of  lymphocytes  to  that  of 
polynuclear  leucocytes.  Their  protoplasm  contains  large,  strongly  acidophile 
granules  which  are  believed  to  be  integral  parts  of  a  cytoreticuhim  (Heiden- 
hain,  Gulland).  Their  nuclei  are  coarsely  reticulated  and  usually  bilobed,  the 
lobes  are  more  often  separate  than  in  the  neutrophile  cells,  and  they  stain  rather 
faintly  with  nuclear  dyes. 

5.  Mast-cells  are  mononuclear  or  polynuclear  cells  of  different  sizes,  whose 
characteristic  feature  is  the  presence  of  large  and  small  strongly  basophile 
granules.  These  granules  do  not  reflect  the  pure  color  of  many  stains,  but 
are  metachromatic,  especially  with  thionin.  A  few  mast-cells  are  always  to  be 
found  in  normal  blood,  but  when  present  in  any  considerable  numbers  they  are 
pathognomonic  of  myelogenous  leukemia.  Levaditi  describes  small  acidophile 
granules  in  mast-cells.  The  mast-cell  of  the  blood  is  entirely  different  in 
appearance  from  the  mast-cell  of  the  tissues. 

Leucocytes  in  Pathological  Blood. — Besides  the  above  forms  of  color- 
less cells  which  alone  are  present  in  normal  blood,  other  types  of  cells  are  seen 
in  the  circulation  in  disease. 

Myelocytes  are  mononuclear  cells  with  neutrophile  or  with  eosinophile  gran- 
ules.    Three  types  of  myelocytes  should  be  distinguished: 

(a)  Ehrliclis  myelocyte  is  a  medium-sized  cell  with  pale,  usually  central 
nucleus,  and  neutrophile  granules.  It  is  found  in  many  morbid  conditions, 
especially  in  leukemia  and  secondary  anemia.  Ehrlich  has  described  as 
"  neutrophile  pseudolymphocytes  "  very  small  myelocytes  with  densely  stain- 
ing nuclei,  which  were  seen  in  hemorrhagic  small-pox. 

(&)  CorniVs  myelocyte  is  a  large  cell,  much  larger  than  a  polynuclear  leu- 
cocyte, with  pale  eccentric  nucleus  and  neutrophile  granules.  It  is  found  almost 
exclusively  in  myelogenous  leukemia,  and  less  frequently  in  v.  Jaksch's  anemia. 

(c)  Eosinophile  myelocytes  may  resemble  the  eosinophile  cells  of  normal 
blood,  except  that  their  nuclei  are  single.  Such  cells  are  abundant  in  mye- 
logenous leukemia,  occur  not  infrequently  in  v.  Jaksch's  anemia,  and  have  been 
found  in  myxedema  by  Mendel,  in  some  infectious  diseases  by  Turck,  and  in 
pernicious  malaria  by  Bignami.  Or  their  granules  may  be  of  excessive  size, 
in  which  case  they  are  pathognomonic  of  myelogenous  leukemia.  Most  myelo- 
cytes possess  true  acidophile  nucleoli  (Jolly). 

Classification  of  Leucocytes. — Although  the  leucocytes  were  discovered 
by  Nasse  in  1835,  the  first  scheme  of  classification  based  upon  their  supposed 
points  of  origin  was  offered  by  Virchow,  who  divided  the  colorless  cells  into 
lymphocytes  derived  from  the  lymph  nodes,  splenocytes  from  the  spleen,  while 
polynuclear  cells  he  regarded  as  developmental  forms  of  the  mononuclear. 
Similarly,  Einhorn,  a  pupil  of  Ehrlich,  classed  the  leucocytes  as:  (1)  lympho- 
cytes, small  and  large,  derived  from  the  lymph  nodes;  (2)  myelogenous  cells 
(eosinophiles)  from  the  marrow,  and  (3)  large  mononuclear,  transitional,  and 
polynuclear  cells,  from  spleen  or  marrow. 

In  1865  M.  Sclmltze  described  the  leucocytes  as   (1)  nongranular   (large 


DISEASES    OF   WOUNDS  107 

and  small  mononuclears);  (2)  finely  granular  (neutrophiles),  and  (3)  coarsely 
granular  (eosinophilee  and  mast-cells).  He  believed  thai  all  granules  and 
nil-  represenl  developmental  form-  of  one  aeries. 

Lowit's  classification,  based  on  the  morphology  of  the  nucleus,  included 
Bmall  and  large  mononuclear  cells  (lymphocytes),  "transitional"  leucocytes, 
and  polynuclear  leucocytes.  Regarding  solely  the  nucleus,  Lowil  found  no 
difficultv  in  deriving  all  leucocytes  in  one  series  of  cells.  It  remained  for 
Ehrlich  to  establish  the  essential  distinction  between  leucocytes  by  demon- 
strating specific  microchemical  reactions  in  the  granules  of  Schultze. 

Ehrlich  divided  the  anilin  dyes  into  three  main  -roup-:  i  l)  Basic  <\yi-<, 
as  hematoxylon,  methylene  blue,  thionin,  etc,  act  as  bases,  uniting,  with  ^elect- 
ive power  in  the  order  named,  with  the  acid  principles  of  cells  (  oucleinic  acid  ). 
(2)  Acid  dyes,  as  eosin,  fuchsin,  aurantia,  act  as  acids,  and  unite  with  the 
basic  principles  of  cells.  (3)  Neutral  dyes.  When  certain  basic  and  acid 
dyes  are  mixed  a  compound  is  formed  of  modified  staining  qualities  which 
unites  with  certain  cell  structures  not  readily  stained  by  other  method-.  Such 
a  mixture  Ehrlich  calls  a  neutrophile  stain,  an  example  of  which  is  the  triacid 
mixture.      Neutral  red  seems  also  to  fall  in  this  'da--. 

According  to  their  reactions  to  these  dyes  the  granules  of  leucocytes  in 
human  blood  may  he  divided  into  three  main  groups,  basophile,  acidophile 
(oxyphile),  and  neutrophile,  and  on  these  grounds  the  present  classification 
of  leucocyte-  is  based,  as  follows: 

1.  Basophile  Cells:  Mast-cells  (y-granules).  Granule-  strongly . basophile. 
Lymphocytes.  Protoplasm  strongly  basophile.  Liny1"  mononuclear  leucocytes. 
Protoplasm  slightly  basophile. 

2.  Neutrophile  Cells:  Polynuclear  leucocytes.  Xeutrophih  e  granules. 
Myelocytes.     Neutrophile  granules. 

3.  Eosinophil?  Cells:  Eosinophil*-  leucocytes.  Large  acidophile  granules 
(a-yranules).     Eosinophile  myelocytes.     Large  acidophile  granules. 

Ehrlich  also  described  /8-granules  which  are  amphophile,  stain  by  both 
basic  and  acid  <lyes,  and  are  found  in  some  marrow  cells,  and  8-granules  which 
are  small  basophile  granules  said  to  occur  in  some  mononuclear  cells. 

In  estimating  the  leucocyte-  in  both  health  and  disease  one  is  confronted 
by  a  great  variety  of  disturbing  factors,  including  the  causes  of  distinct  physi- 
ological leucocytosis,  the  individual  peculiarities  of  the  subject,  and  the  ordi- 
nary variations  in  the  local  condition  of  the  part  from  which  the  blood  is  taken. 
All  that  has  been  said  regarding  accidental  variations  in  red  cells  applies  equally 
to  leucocyte-,  and  one  musl  carefully  consider  the  effects  of  vasomotor  phenom- 
ena, of  changes  in  the  volume  of  plasma,  ami  of  the  presence  of  inflammation 
or  edema.  Tt  should  he  remembered  that  while  the  leucocytes  remain  nearly 
uniform  in  the  great  vessels,  their  proportions  in  the  capillary  circulation  may 
change  more  rapidly  than  those  of  the  red  cells,  owing  probably  to  chemotactic 
influences.  The  most  common  sources  of  error  may  he  avoided  by  taking  speci- 
mens about  four  hours  after  a  meal  and  at  the  same  hour  each  day. 


108      DISEASES    CAUSED   BY   THE   PUS-PRODUCING   BACTERIA 

Proportions  of  Vaeious  Forms  of  Leucocytes. — The  proportions  of 
the  different  forms  of  leucocytes  in  normal  blood  are  even  less  fixed  than 
their  numbers.  Ehrlich's  figures  may  well  serve  as  a  standard  for  healthy 
adults. 

Lymphocytes,  twenty-two  to  twenty-five  per  cent. 

Large  mononuclear  and  transitional  leucocytes,  two  or  four  per  cent. 

Polynuclear  neutropliile  leucocytes,  seventy  to  seventy-two  per  cent. 

Eosinopihile  cells,  two  to  four  per  cent. 

^Last-cells,  one  half  to  two  per  cent. 

The  chief  variations  from  these  limits  which  deserve  mention  are  the 
maximum  percentages  given  by  Rieder  for  lymphocytes  (thirty  per  cent)  and 
by  Limbeck  for  polynuclear  leucocytes  (eighty  per  cent).  In  childhood  the 
proportion  of  lymphocytes  is  usually  much  increased  (fifty-five  to  sixty-six 
per  cent),  and  that  of  polynuclear  cells  correspondingly  diminished  (twenty- 
eight  to  forty  per  cent).     (Gundobin,  Eieder.) 

The  following  description  of  the  method  of  estimating  the  number  of 
leucocytes  in  the  blood  is  also  quoted  from  Ewing  ("  Clinical  Pathology  of  the 
Blood/'  second  edition,  1903,  page  41  et  seq.)  : 

The  Estimation  of  Leucocytes. — The  leucocytes  may  be  counted  by  a  method 
which  requires  a  special  mixing  pipette,  yielding  a  dilution  of  blood  in  the  pro- 
portion of  1:10,  and  a  diluting  fluid  (three  per  cent  acetic  acid,  tinged  with 
gentian  violet)  which  dissolves  the  red  cells,  leaving  only  the  stained  leucocytes 
to  be  counted.  The  same  chamber  is  used  as  for  counting  red  cells,  and  the  same 
procedure  is  followed.  All  the  leucocytes  in  1  sq.  mm.  having  been  counted, 
the  result  is  multiplied  by  100,  giving  the  number  of  leucocytes  per  cubic 
millimeter.  The  disadvantages  early  recognized  in  this  method  are  the  expense 
and  inconvenience  of  an  extra  pipette,  and  a  second  diluting  fluid,  the  time 
required  in  preparing  a  second  specimen,  the  larger  quantity  of  blood  required, 
the  difficulty  sometimes  encountered  in  distinguishing  leucocytes  from  the  detritus 
of  red  cells,  and  the  impossibility  of  separating  and  evenly  distributing  the  cohesive 
leucocytes. 

This  method  has  gradually  been  replaced  to  a  large  extent  by  the  practice  of 
counting  leucocytes  in  the  same  specimen  prepared  for  counting  the  red  cells.  In 
1892  the  writer  found  that  he  secured  more  uniform  results  with  the  latter  method, 
and  has  since  found  no  inducement  to  return  to  the  former. 

The  Counting  of  Leucocytes  in  the  Same  Preparation  with  the  Bed. — This 
method  requires  the  Zappert  Chamber,  which  was  originally  devised  by  Elsholz  for 
the  estimation  of  eosinophile  cells  in  fresh  blood.  Various  modifications  of  the 
ruling  in  this  chamber  have  been  employed,  one  of  which,  made  by  Leitz,  at  the 
writer's  suggestion,  is  represented  in  Fig.  13. 

With  this  chamber,  using  a  Leitz  lens  Xo.  7,  it  is  possible  to  count  over  9  sq.  mm., 
which  gives  almost  as  many  leucocytes  as  are  counted  in  the  other  method.  When 
the  leucoc}Ttes  are  normal  or  reduced  in  number,  it  is  necessary  to  count  all  there 
are  in  the  available  9  sq.  mm.,  and  if  the  number  is  very  low  it  is  advisable  to 


DISEASES    OF    WOUNDS  109 

prepare  a  second  specimen  in  the  chamber  and  count  the  white  cells  in  18  sq.  nun. 
When  the  leucocytes  are  increased,  9  sq.  nun.,  or  in  cases  of  leukemia,  o'  sq.  mm., 
will  yield  a  Dumber  Large  enough  to  insure  an  accurate  result. 

In  order  to  make  the  leucocytes  visible,  Toisson's  fluid  or  other  solution  should 
contain  enough  methyl  violet  to  stain  these  cells  distinctly.  With  a  little  practice 
the  eye  very  readily  pick-  out  the  bluish,  highly  refractive  leucocyte.-;. 

What   has  been  said   regarding  the  condition  of  the  loca]  circulation,  and  the 

effects  of  pressure  in   expressing  the  hi 1.   is   to  he  specially  emphasized   when 

estimating  the  number  of  leucocytes  in  a  specimen  of  hlood. 

Computation. — Divide  the  number  of  leucocytes  counted  \>y  the  number  of 
square  millimeters  traversed  in  the  count  and  multiply  by  1,000.  The  result  is  the 
number  of  leucocytes  per  cubic  millimeter  of  hlood. 

If  the  original  dilution  is  1:200,  which  ought  not  to  hi'  employed  except  in 
cases  of  leukemia,  the  multiplier  is  2,000.  Thus  if  54  leucocytes  are  counted  in 
!)  sq.  mm.  (dilution  1:100),  the  number  per  c.mm.  is  6,000  (54 -f- 9  X  1,000). 

The  Enumeration  of  Eosinophile  Leucocytes. —  (a)  In  the  Same  Preparation 
with  the  /.'"/  Cells. — When  the  hlood  is  diluted,  1:100,  with  0.6  per  cent  salt  solu- 
tion tinged  with  gentian  violet,  the  leucocytes  retain  their  natural  size  and  shape 
and  eosinophile  cells  can  be  readily  identified  by  their  large,  greenish,  refractive 
granules.  In  cases  of  myelogenous  leukemia  this  method  is  satisfactory,  but  when 
the  eosins  are  present  in  their  usual  numbers  (one  to  five  per  cent),  one  must 
count  a  larger  number  than  can  he  found  by  tbis  method.  The  usual  expedient 
is  to  estimate  their  percentage  from  a  dried  specimen  of  blood,  and  tben  to  calcu- 
late their  number  from  the  total  number  of  all  leucocytes  counted  by  other  methods. 
Thus,  if  the  count  sbows  12,000  leucocytes  per  cubic  millimeter,  and  the  dried  blood 
slide  shows  two  per  cent  of  eosins,  their  number  will  be  240  per  cubic  millimeter. 
This  method  is  sufficiently  accurate  for  clinical  purposes. 

(b)  By  Means  of  Thoma's  Special  Pipette  for  the  Enumeration  of  Leucocytes. 
— Klein,  Mueller  and  Reider,  and  Elsholz  have  employed  methods  for  the  accurate 
estimate  of  eosinophile  cells  adapted  to  finer  clinical  work  and  to  experimental 
research.  They  use  the  large  pipette  of  Thoma,  which  gives  a  dilution  of  1:  10. 
The  capillary  tube  is  Idled  with  blood  to  the  mark  1,  and  the  bulb  is  half  tilled 
with  the  following  solution:  watery  eosin  (two  per  cent),  7  c.c;  glycerin,  45  c.c. : 
aq.  dest,  55  c.c.  After  shaking  three  to  four  minutes  the  bulb  is  filled  to  the 
mark  2  with  the  following  staining  fluid:  aq.  dest.,  15  c.c;  gentian  violet,  cone, 
aq.  sol.,  5  drops;  alcohol,  1  drop. 

In  specimens  thus  prepared,  both  neutrophile  and  eosinophile  leucocytes  are 
readily  distinguished,  the  eosinophile  cells  being  particularly  brilliant.  The  red 
cells  are  dissolved  and  the  leucocytes  concentrated  so  that  a  sufficient  number  <^( 
eosinophile  cells  may  be  counted. 

Zapjpert's  extensive  studies  of  eosinophile  leucocytes  were  conducted  with  speci- 
mens diluted  in  the  large  pipette  of  Thoma.  by  the  following  solution:  one  per  cent 
osmic-acid  sol.,  5  c.c,  to  which  are  added  5  drops  of  a  filtered  mixture  (aq.  dest.. 
10  c.c.)  ;  glycerin,   10  c.c;  one  per  cent  watery  eosin.  5  c.c. 

The  Histological  Examination  of  Blood  (Ewing). — The  greater  part  o( 
the  examination  of  hlood  is  conducted  with  dry  stained  specimens.  To  prepare 
such  specimens  for  staining  one  requires  only  polished  glass  slides  and  a  Bunsen 
gas  burner.     The  glass   slides   must   be  thoroughly  cleaned  with  soap   and  water. 


110       DISEASES    CAUSED    BY    THE    PUS-PRODUCING   BACTERIA 

dried,  and  kept  free  from  dust.  Passing  them  a  few  times  through  a  flame  facili- 
tates the  even  spreading  of  the  cells. 

A  rather  small,  compact  drop  of  blood  expressed  from  the  finger  tip  under 
the  usual  precautions  is  lightly  scraped  off  with  the  polished  edge  of  one  slide 
and  applied  to  one  end  of  a  second  slide  which  should  lie  on  firm  support.  When 
the  blood  has  spread  along  the  edge  of  the  smearer  it  should  be  slowly  and  firmly 
drawn  over  the  surface  of  the  receiving  slide.  The  drop  should,  if  possible,  be  small 
enough  to  be  exhausted  in  the  smearing,  and  the  thickness  of  the  layer  can  be  fully 
controlled  by  the  degree  of  pressure.  The  blood  should  be  pushed  before  the 
smearer  and  not  trailed  after. 

Many  prefer  to  use  cover-glasses  in  spreading  the  blood.  One  polished  cover- 
glass  is  touched  to  the  drop  of  blood  and  applied  to  a  second  cover,  all  corners 
projecting.  AYhen  the  blood  has  spread  to  the  edges,  the  cover-glasses  are  gently 
spread  apart  without  joressure.  The  cover-glasses  should  be  handled  with  forceps, 
otherwise  the  moisture  of  the  finger  will  often  crenate  many  cells. 

The  writer  prefers  to  use  glass  slides,  finding  that  beginners  are  much  more 
successful  with  the  slides  than  with  cover-glasses;  that,  after  very  little  practice, 
every  specimen  can  be  spread  successfully;  that  forceps  are  not  required;  that 
slides  may  be  handled  and  transported  without  fear  of  breakage;  that  they 
need  not  be  mounted,  and,  therefore,  do  not  fade  like  cover-glass  specimens, 
which  require  mounting  in  balsam;  that  they  may  safely  be  fixed  in  the 
free  flame. 

After  sjoreading,  all  specimens  should  be  well  dried  in  the  air.  They  may  then 
be  kept  for  weeks  if  wrapped  in  tissue  paper  and  kept  from  moisture,  but  it  is 
better  to  fix  them  at  once. 

Fixation — 1.  Heat. — In  routine  work  one  ma}r  discard  all  other  methods  for 
that  of  fixation  in  the  free  fame  of  a  Bunsen  burner.  The  slide,  specimen  side 
up,  is  passed  slowly  through  the  flame  until  it  is  decidedly  too  hot  for  the  hand 
to  bear.  At  this  temperature,  which  probably  varies  between  110°  and  150°  C, 
fixation  is  complete  in  one  to  two  minutes. 

A  little  practice  will  give  the  confidence  necessary  to  heat  the  slides  hot  enough, 
as  one's  initial  failures  from  this  method  almost  always  result  from  incomplete 
fixation  and  subsequent  vacuolization  of  the  red  cells.  Overheated  slides  can 
usually  be  seen  to  change  color  in  the  flame,  after  which  the  red  cells  stain  yellowish 
with  eosin.  The  beginner  is  strongly  recommended  to  perfect  himself  in  this  simple 
method  of  fixation. 

Small  ovens  provided  with  a  thermometer  are  made  for  the  fixation  of  blood 
slides,  and  may  be  used  when  man}*-  specimens  are  in  hand,  or  when  one  does  not 
care  to  risk  the  free  flame.  Specimens  should  be  exposed  five  to  ten  minutes  to 
a  temperature  of  110°  to  120°  C. 

2.  Alcohol. — Fixation  for  ten  to  thirty  minutes  in  ninety-seven  per  cent  alcohol, 
or  in  equal  parts  of  alcohol  and  ether,  is  a  very  reliable  method  in  general  use. 
Specimens  may  be  left  in  alcohol  twenty-four  hours,  but  do  not  then  stain  quite 
so  well.  There  appears  to  be  no  advantage  in  adding  ether  to  the  alcohol,  which 
even  without  mixture  with  the  more  volatile  agent  must  frequently  be  replaced. 
Methyl  alcohol  fixes  much  more  rapidly  than  ethyl,  requiring  only  one  to  two 
minutes.  It  may  be  advantageously  employed  as  a  routine  fixative,  and  it  is  used 
as  a  combined  fixative  of  blood  and  solvent  of  dyes  in  Jenner's  and  Goldhorn's 


DISEASES   OF    WOUNDS  111 

Btains.     Fixation  in  alcohol  is  to  be  specially  recommended  for  the  malarial  para 
site,  Imi  is  unsatisfactory  when  Ehrlieh's  triacid  stain  is  i<>  be  used. 

;i.  Fixation  by  Vapors. — Specimens  may  be  fixed  by  being  laid,  specimen  side 
down,  over  a  wide-mouthed  bottle  containing  twenty-five  per  cenl  formalin,  to 
which  the  exposure  is  five  minutes,  or  two  per  cent  osmic  acid,  i<»  which  expose  two 
minutes.  Both  these  fluids  have  to  be  replaced  frequently,  they  considerably  alt«  r 
the  staining  relations  of  the  blood  cells,  and  are  inferior  to  other  methods  of 
fixation. 

1.  Fixation  without  Drying. — roily  and  others  claim  that  fixation  after  drying 
destroys  many  of  the  essential  characters  of  leucocytes,  which  may  be  demonstrated 
in  specimens  fixed  while  moist  in  solutions  of  chromic  acid.  Flemming's  wronger 
solution  gave  the  best  results  in  .lolly's  hands  (one  per  cent  chromic  acid.  15  parts; 
two  per  cent  osmic  acid,  f  parts;  glacial  acetic  acid,  1  part).  Other  fixative-; 
recommended  for  the  same  purpose  are  saturated  bichlorid  in  0.6  per  cent  salt 
solution  (Hermann's  fluid).  All  these  fixatives  undoubtedly  give  better  demon- 
stration of  nuclear  structures  and  mitotic  figures  than  can  be  obtained  after  fixation 
with  drving. 

Methods  of  Staining  Dry  Blood  Specimens. — 1.  Eosin  and  Methylene  Blue. — 
The  solutions  required  are:  a  saturated  alcoholic  solution  of  Ehrlieh's  blood  eosin; 
a  sat  mated  watery  solution  (one  per  cent)  of  Ehrlieh's  rectified  methylene  blue. 
The  latter  should  he  at  least  one  week  old,  as  fresh  solutions  lack  selective  quality 
and  stain  the  specimen  diffusely.  After  several  weeks  methylene  blue  in  solution 
diminishes  in  staining  power,  while  the  alcoholic  eosin  ahsorbs  water,  and  becomes 
less  selective  and  more  powerful. 

//;  staining,  flood  the  specimen  with  eosin  for  a  few  seconds  and  wash  in  water. 
If  the  stain  is  not  effective  add  more  eosin,  hut  the  water  on  the  slide  dilutes  the 
alcohol  and  renders  the  second  application  of  eosin  much  more  powerful  than  the 
first.  Next  flood  the  specimen  repeatedly  for  one  minute  with  methylene  blue, 
wash  hastily  in  water,  and  dry. 

This  method  may  be  recommended  for  all  ordinary  examinations.  The  blood 
is  stained,  thus  readily  distinguishing  the  various  forms  of  normal  leucocyte-. 
It  does  not  stain  neutrophile  granules  in  leucocytes  unless  the  action  of  eosin 
has  been  prolonged,  in  which  case  the  neutrophile  leucocytes  can  he  distinguished 
from  the  eosinophile  only  by  the  size  of  the  granules.  Its  chief  advantage  is 
the  clear  differentiation  of  basophilic  leucocytes  and  of  nuclear  structures.  It 
clearly  demonstrates  the  malarial  parasite,  hut  in  this  field  is  greatly  inferior  to 
Nocht's  method.  Its  chief  disadvantage  is  the  danger  of  overstaining  with  eosin, 
which  prevents  the  full  action  of  methylene  blue. 

2.  Ehrlieh's  Triacid  Mixture. — This  fluid  has  the  following  composition: 

Saturated  watery  solution  of  orange  (! 120   1  :'>•">  c.C. 

Saturated  watery  solution  acid   fuchsin 80  1  65  c.c. 

Saturated  watery  solution  methyl  green 125  c.c. 

To  these  add  : 

Aqua "oil  c.c. 

Absolute  alcohol  '-,|)()  c.c. 

Glycerin   100  c.c. 


112      DISEASES    CAUSED   BY   THE   PUS-PKODUCING   BACTEEIA 

The  attempt  to  prepare  this  mixture  is  not  always  successful.  The  smaller 
quantities  of  orange  G  and  acid  fuchsin  are  best  employed,  and  the  solution  of 
methyl  green,  well  seasoned,  should  be  added  slowly,  with  stirring,  to  the  mixture 
of  the  other  dyes.  The  water  should  be  added  next,  then  the  alcohol,  and,  finally, 
the  glycerin,  with  constant  stirring.  After  standing  one  week  the  mixture  is  ready 
for  use.     Griibler's  preparation  of  tliis  mixture  is  in  the  market  and  is  reliable. 

In  staining  it  is  only  necessary  to  flood  the  specimen  with  the  dye  for  one  to 
two  minutes,  and  wash  hastily  in  water.  It  cannot  overstain,  but  overheated 
specimens  are  usually  faint,  and  the  red  cells  are  yellowish.  It  stains  neutrophil e 
and  eosinophile  granules  deep  red,  the  latter  being  distinguished  by  their  size.  It 
is,  therefore,  indispensable  in  the  diagnosis  of  leukemia.  It  is  a  poor  nuclear  stain, 
fails  to  demonstrate  the  structure  of  normal  mononuclear  leucocytes,  and  does  not 
stain  the  malarial  parasite.  On  account  of  the  uniformity  of  its  results  many 
prefer  it  to  eosin  and  methylene  blue  as  a  routine  method. 

3.  Jenner's  Stain. — Jenner's  method  of  fixing  and  staining  blood  has  now  with- 
stood sufficient  trial  to  warrant  its  acceptance  as  one  of  the  most  important  recent 
methods  in  blood  technics.  The  specimens  are  fixed  and  stained  in  the  same  solu- 
tion, which  is  prepared  as  follows :  equal  parts  of  1.2  per  cent  to  1.25  per  cent  of 
watery  solution  of  Griibler's  yellow  water-soluble  eosin  and  of  one  per  cent  watery 
solution  of  Griibler's  medicinal  methylene  blue  are  mixed  together  in  an  open  basin, 
thoroughly  stirred,  and  allowed  to  stand  twenty-four  hours.  The  mixture  is  then 
filtered,  dried  in  the  air,  or  oven,  at  55°  G,  the  filtrate  powdered,  shaken  up  with 
distilled  water,  and  washed  on  a  second  filter.  It  is  again  dried,  powdered,  and 
stored  in  bottles  for  use.  The  stain  is  prepared  by  dissolving  0.5  gm.  of  the  pow- 
der in  100  c.c.  pure  methyl  alcohol   (Merck's  "for  analytical  purposes"). 

Very  thin  smears  of  blood,  made  on  thoroughly  clean  slides,  are  dried  in  the 
air.  The  dye  is  poured  on  the  specimen,  and  staining  is  complete  in  one  to  three 
minutes.  The  specimens  are  washed,  preferably  in  distilled  water,  until  of  a  pink 
color,  which  usually  appears  in  ten  seconds.  All  the  cells,  their  nuclei,  and  the 
various  granules  are  well  differentiated,  while  the  malarial  parasite  is  densely 
stained  and  only  in  the  larger  parasites  does  the  chromatin  fail  to  appear  deeply 
red  stained.  For  this  last  purpose  the  method  is  inferior  to  ISTocht's.  The  powder 
or  fluid  dye  may  be  obtained  from  New  York  dealers. 

ISTormal  Variations  of  Leucocytes. — In  health  the  number  of  white 
cells  in  the  blood  varies  within  wide  limits  from  a  variety  of  causes.  The 
number  is  higher  in  the  new-born  than  in  adults,  greater  after  the  ingestion  of 
food,  greater  during  pregnancy.  In  the  healthy  adult,  the  number  may  vary 
in  different  subjects  and  at  different  times — according  to  Rieder,  between 
9,600  and  4,200.  Still  wider  variations  occur,  according  to  other  observers. 
The  different  forms  of  white  cells  also  vary  greatly  in  the  proportions  of 
their  occurrence.     Ehrlich's  figures  for  healthy  adults  are  as  follows : 

Lymphocytes   22-25  per  cent. 

Large  mononuclear  and  transitional  leucocytes 2-4         " 

Polynuelear  neutrophile  leucocytes   70-72         " 

Eosinophile   cells    2-4         " 

Mast-cells  0.5-  2 


DISEASES    pF    WOUNDS  11:5 

Pathological  Leuoooytoses. —  Pathological  leucocytoses  occur  after  hem 
orrhage,  as  the  resull   "I   cachexias,  as  an   ante-mortem   condition    in    various 
diseases,  ami  as  the  resull  of  inflammations.     From  a  practical  point  of  view 
in  surgical  diagnosis,  inflammatory  leucocytosis  is  the  most  important  variety, 

and   it    is  to  be  borne  in   mind   that    in   this  condition   the  polynuclear  tonus   are 

those  chiefly  concerned  in  the  increase. 

The  pbactical  diagnostic  value  of  the  leucocyte  count  i.\  pyogenic 

imkctions  may  bo  summarized  as  follows: 

1.  In  the  presence  of  an  evidently  acute  and  intense  purulent  infection. 
absence  of  leucocytosis  indicates  that  the  system  is  making  hut  feehle  efforts 
to  overcome  the  infection;  a  high  percentage  of  polynuclear  cells  is  always 
present  ;  the  prognosis  is  grave. 

2.  In  the  case  of  ahscesses  or  other  localized  purulent  collections  which 
have  existed  for  some  time,  absence  of  leucocytosis  indicates  that  the  bacteria 
are  dead,  or  that  the  pus  is  entirely  shut  off  from  the  general  circulation;  i.  e., 
encapsulated  by  granulation  or  fibrous  tissue1. 

3.  The  above  conditions  excepted,  pyogenic  infections  are  regularly  at- 
tended by  an  increased  number  of  leucocytes  in  the  blood ;  the  increase  involves 
a  relative  increase  of  the  polynuclear  forms. 

4.  A  high  degree  of  leucocytosis  indicates  an  intense  process,  although  the 
inflammatory  focus  may  be  large  or  small. 

5.  A  steadily  increasing  number  of  leucocytes  or  a  relative  increase  in  poly 
nuclear  cells  indicates  that  the  inflammatory  process  is  increasing  in  extent 
or  in  severity,  or  both. 

6.  A  sudden  marked  increase  in  the  leucocyte  count  indicates  often  that 
the  purulent  infection  has  invaded  new  structures — a  joint,  the  peritoneum, 
the  cranial  cavity — or  that  the  process  is  spreading  rapidly. 

7.  Deep-seated  foci  of  suppuration  not  accessible  to  ordinary  methods  of 
examination — such  as  lie,  for  example,  in  the  medulla  of  the  long  bones,  in 
the  perirenal  connective  tissue,  in  the  liver,  or  in  the  venous  sinuses  of  the 
cranium — may  give  rise  to  leucocytosis  before  any  apparent  local  si«ms  or 
symptoms  exist.  In  such  instances  the  leucocyte  count  may  aid  greatly  to 
establish  a  probable  diagnosis. 

8.  A  moderate  increase  of  leucocytes  is  15,000  per  cubic  millimeter;  a 
large  increase  is  30,000;  above  that  number  is  very  high  indeed,  ami  indicates 
an  intense  infection. 

9.  After  an  abscess  or  other  inflammatory  focus  has  been  evacuated,  the 
number  of  leucocytes  falls  slowly  or  rapidly  until  the  normal  number  is  reached 
after  a  variable  time.  A  subsequent,  rise  often  indicates  imperfect  drainage 
or  pocketing  of  pns. 

10.  A  number  of  conditions  may  arise,  either  independently  or  after  sur- 
gical operations,  such  that  a  suspicion  may  be  aroused  of  the  presence  of  pus. 
A  normal  leucocyte  count  and  a  low  polynuclear  count  are  valuable  aids  in 
eliminating  a  pyogenic  infection.     Such  are  typhoid  and  malarial  fevers,  many 

9 


114       DISEASES    CAUSED    BY    THE    PUS-PEODTJCIXG   BACTEPJA 

forms  of  colic,  affecting  the  abdominal  organs — the  kidney,  the  biliary  passages, 
the  intestine,  the  uterus — also  abdominal  neuralgias.  (See  also  section  on 
appendicitis,  Chapter  XXIX,  for  further  details.) 

Pyemia. — Pyemia  is  that  form  of  pyogenic  infection  in  which  disseminated 
foci  of  suppuration  are  produced  by  the  lodgment  of  infectious  emboli  in  the 
small  arteries  and  capillaries.  The  emboli  originate  in  infected  thrombi  formed 
in  veins,  the  seat  of  a  thrombophlebitis,  caused  by  the  growth  in  the  vein  of 
one  or  other  of  the  pus-producing  microbes.  The  vein  may  be  infected  from 
without  by  extension  through  its  walls  of  an  infectious  inflammation  of  the 
surrounding  tissues,  or  bacteria  in  the  circulating  blood  may  in  certain  situa- 
tions become  adherent  to  the  wall  of  the  vein,  there  to  grow  and  multiply.  An 
infected  thrombus  is  thus  formed,  and  may  become  the  source  of  emboli  which 
lodge  in  distant  parts.  When  such  emboli,  bearing  actively  growing  pus 
microbes,  finally  lodge  in  a  minute  vessel,  the  area  supplied  by  such  vessel 
becomes  anemic,  the  microbes  speedily  multiply  in  its  substance,  and  a  focus 
of  suppuration — an  abscess — is  thereby  formed.  Any  of  the  pus-producing 
organisms  may  cause  pyemia.  One  or  other  of  the  pyogenic  staphylococci 
oftener  than  others,  and  the  Staphylococcus  pyogenes  aureus  very  com- 
monly. 

1.  Pyemia  may  originate  from  an  infected  wound  at  any  time  until  healing 
is  complete. 

2.  From  any  purulent  focus  in  the  tissues  containing  living  pus  microbes, 
irrespective  of  the  age  of  such  a  focus;  i.  e.,  after  an  infected  wound  long 
healed. 

3.  As  the  result  of  subcutaneous  injuries,  usually  of  a  trifling  character, 
which  have  produced  a  place  of  diminished  resistance  in  a  situation  favorable 
to  the  implantation  upon  the  inner  walls  of  small  veins  of  pus-producing  germs 
circulating  in  the  blood   (osteomyelitis). 

The  disease  is  characterized  by  the  formation  of  abscesses  in  various  situa- 
tions, by  fever  of  an  intermittent  type,  and  by  chills.  The  chills  are  usually 
accompanied  by  a  sudden  marked  rise  of  temperature,  and  are  generally  a 
part  of  the  reaction  of  the  system  to  the  lodgment  of  a  new  embolus  and  the 
formation  of  a  new  focus  of  suppuration.  In  the  course  of  a  few  hours 
the  temperature  falls  to  normal  or  below,  and  this  fall  is  accompanied  by 
sweating. 

Methods  of  Infection  and  Varieties  of  Pyemia. — For  purposes  of 
description  we  may  divide  cases  of  pyemia  into  several  groups :  Those  in  which 
there  exists  an  infected  wound,  old  or  recent,  or  an  acute  or  chronic  suppurative 
process  readily  accessible  to  observation,  and  those  arising  from  some  hidden 
focus  of  pus  not  readily  recognized  on  superficial  examination,  due  to  a  wound 
already  long  healed  or  to  an  encapsulated  pus  focus  containing  living  microbes 
suddenly  set  free  in  the  circulation,  or  to  some  acute  process  originating 
apparently  de  novo,  and  so  situated  that  local  signs  and  symptoms  are,  for  a 
time  at  least,  not  distinctive.     In  those  cases  following  a  recent  injury,  or  an 


DISEASES   OF    WOUNDS  I  15 

acute  inflammatory  condition  whose  signe  and  symptoms  are  evident,  the 
diagnosis  of  pyemia  offers  no  difficulties.  In  those  arising  after  ;i  wound  has 
long  lulu  healed,  or  from  souk-  hidden  and  unsuspected  inflammatory  focus, 
for  a  time  al  leasl  the  diagnosis  may  ool  !»•  clear.  To  this  category  belong 
some  cases  of  acute  osteomyelitis  <>!'  the  long  bones. 

( lertain  kinds  of  injuries  and  diseases  are  especially  liable  to  the  occurrence 
of  pyemia.  Compound  fractures  of  the  long  bones  were,  in  preantiseptic  days, 
very  commonly  followed  by  death  from  this  cause;  infected  wounds  of  large 
joints;  severe  crushing  injuries  of  the  extremities,  if  neglected.  Among  dis- 
eases, carbuncle  of  the  lip  and  erysipelas  of  the  face  are  sometimes  followed 
by  pyemia  due  to  thrombophlebitis  of  veins  communicating  with  the  sinuses 
of  the  cranium;  inflammation  <>f  the  middle  ear  and  mastoid  process  of  the 
temporal  bone  due  to  the  close  proximity  of  the  sigmoid  sinus.  Septic  infec- 
tion of  the  interior  of  the  uterus  sometimes  has  pyemia  as  a  sequel.  Suppura- 
tive lesions  of  the  intestines— notably  appendicitis — are  sometimes  followed 
by  a  thrombophlebitis  of  the  veins  of  the  mesentery;  in  this  manner  the  infec- 
tion is  carried  to  the  branches  of  the  portal  vein  in  the  liver,  and  a  suppura- 
tive process  is  thus  inaugurated  in  the  liver  substance  around  the  branches 
of  this  vein. 

The  metastatic  abscesses  of  pyemia  occur  in  many  situations.  The  heart  and 
lungs  are,  of  course,  the  organs  through  which  the  emboli  must  first  pass,  and 
abscesses  in  the  heart  muscle,  or  sometimes  endocarditis  or  pericarditis,  result. 
Ahscesses  in  the  lungs  are  common;  many  of  the  emboli  are  small  enough  to 
pass  through  the  lung  capillaries,  enter  the  general  circulation,  and  lodge  in 
the  kidneys,  the  liver,  the  spleen,  the  muscles,  bones,  joints,  lymph  glands,  the 
parotid,  the  brain,  or  other  tissues,  to  become  centers  of  suppuration. 

Clinical  Course. — The  course  of  the  disease  varies  a  good  deal  in  differ- 
ent cases.      In   the   most  acute  forms   an   intense  septicemia  coexists,   and    the 

st mlarv   foci   hardly  have  time   to   produce  symptoms   heWe   death   occurs — 

often  after  eight  or  ten  days  or  less.  Subacute  cases  run  their  course  in  three 
or  four  weeks,  and  chronic  cases  may  last  for  many  months.  In  the  more 
rapidly  fatal  cases  the  secondary  foci  are  often  numerous,  and  situated  in  the 
viscera.  In  those  which  are  less  acute  the  metastatic  foci  are  usually  fewer. 
They  may  he  situated  in  the  viscera,  or  quite  often  in  the  bones,  joints,  or 
muscles.  The  presence  of  the  secondary  ahscesses  may  give  rise  to  marked 
symptoms  or  to  none  at  all.  according  to  whether  they  seriously  interfere  with 
important  functions  or  not. 

An  endocarditis,  a  pleuritis,  a  nephritis  will  he  recognized  by  the  ordinary 
signs  of  these  conditions;  a  brain  abscess  or  a  meningitis  will  produce  symp- 
toms more  or  less  characteristic,  etc.:  headache,  delirium,  coma,  or  paralysis 

of  special   senses  or  groups  of  muscles.       Pyemic  ahscesses    in    the  muscles   and 

in  joints,  and  in  fact  in  all  ordinarily  accessible  regions,  usually  give  pise  to 
a   tar  less   intense   inflammatory   reaction    than   d<>  ordinary    acute    proces 
They  are  therefore  less  painful  and  less  tender,  and   may  only  he  discovered 


116      DISEASES    CAUSED   BY   THE   PUS-PRODUCING   BACTERIA 

by  accident,  since  redness  of  the  skin  overlying  the  abscess  is  often  absent. 
The  presence  of  swelling  and  fluctuation  in  a  joint  or  the  formation  of  a  rather 
diffuse  fluctuating  or  boggy  swelling  in  the  muscles  of  a  limb,  and  perhaps 
a  complaint  of  slight  pain  or  mere  discomfort  from  the  patient,  may  be  all 
to  attract  attention  to  an  abscess  which  may  contain  a  pint  of  pus. 

Symptoms. — The  symptoms,  constitutional  and  local,  of  pyemia  vary  a 
good  deal  according  to  the  degree  of  accompanying  septicemia,  the  acute  or 
chronic  course  which  the  disease  may  assume,  and  the  situation  of  the  metas- 
tatic foci.  If  pyemia  begins  while  the  individual  is  suffering  from  an  infected 
wound  or  acute  septic  inflammation,  the  occurrence  of  a  chill  and  a  sudden 
rise  of  temperature  to  104°  to  106°  E.,  followed  by  as  rapid  a  fall,  nearly  or 
to  the  normal,  and  profuse  sweating,  will  at  once  lead  to  the  suspicion  of  an 
embolic  metastasis.  The  pulse  undergoes  a  corresponding  elevation  along  with 
the  temperature,  but  remains  rather  rapid  after  the  temperature  has  declined. 
The  occurrence  of  subsequent  chills  and  abrupt  elevations  of  temperature  is 
usually  quite  irregular ;  these  may  succeed  one  another  several  times  in  twenty- 
four  hours,  or  every  day,  or  every  two  or  three  days,  or  there  may  be  inter- 
missions of  a  number  of  days ;  during  these  intermissions  there  may  be  moder- 
ate fever  of  a  continuous  or  remittent  type,  or  none  at  all.  When  the  chills, 
fever,  and  sweats  occur  regularly,  the  general  signs  and  symptoms  may  closely 
resemble  malarial  fever.  The  pulse  remains  rapid  even  during  these  inter- 
missions. 

Throughout  the  disease  there  is  loss  of  appetite,  a  coated  tongue,  often  a 
foul  breath — sometimes  the  odor  of  the  breath  is  cadaveric  in  character,  some- 
times of  a  sweetish,  sickening  quality ;  nausea  and  vomiting  are  not  uncommon. 
As  the  disease  progresses,  diarrhea  is  often  developed ;  the  skin  becomes  tinged 
with  yellow — this  jaundice  is  usually  of  a  hematogenous  origin,  less  often  it  is 
due  to  a  catarrhal  inflammation  of  the  intestine,  causing  obstruction  at  the 
mouth  of  the  common  bile  duct,  sometimes  to  metastatic  abscesses  in  the  liver. 
The  spleen  is  enlarged  and  often  palpable.  The  mind  usually  remains  clear 
unless  septicemia  is  also  present.  The  patients  are  restless,  often  irritable,  and 
annoyed  by  lights  and  noises.  They  are  anxious  and  depressed ;  they  sleep 
but  little.  After  each  chill  and  rise  of  temperature  with  the  formation  of  a 
new  metastasis  the  condition  of  the  patient  is  distinctly  worse.  Emaciation  is 
progressive ;  food  is  swallowed,  but  not  assimilated ;  profound  anemia  is  devel- 
oped. The  blood  changes  are :  a  rapid  diminution  of  the  number  of  red  cells 
and  hemoglobin,  with  more  or  less  marked  leucocytosis  of  a  character  similar 
to  that  which  occurs  in  other  suppurative  processes.  Petechial  hemorrhages 
into  the  skin  are  not  unc.omm.on. 

The  condition  of  the  original  wound  undergoes  a  marked  change  when 
pyemia  occurs.  If  active  suppuration  has  been  going  on,  the  wound  discharge 
diminishes.  The  surface  of  the  wound  becomes  pale,  dry,  and  shiny.  Existing 
granulations  become  anemic  and  flabby,  or  melt  away,  leaving  the  wound  sur- 
face covered  by  a  grayish,  necrotic  pellicle.     The  suppurative  process  may,  on 


DISEASES    OF    WOUNDS  117 

tin  other  hand,  advance  in  an  insidious  manner  without  much  external  evidence 
of  its  progress.  The  subcutaneous  tissues,  the  muscles,  and  the  joints,  and  the 
intermuscular  planes  of  a  limb,  may  thus  be  rapidly  but  insidiously  invaded, 
and  new  abscesses  may  thus  appear  from  day  to  day  until  the  whole  limb  is 
riddled.  The  blood-vessels  may  undergo  ulceration,  and  dangerous  or  I 
bleeding  may  occur. 

The  occurrence  of  each  new  chill  should  lead  to  a  careful  examination  for 
the  detection  of  a  new  abscess,  for  Buch  may  be  found  accessible  to  surgical 
treatment.  It'  the  disease  is  fatal,  prostration  becomes  extreme,  and  death 
occurs  from  exhaustion.     Unconsciousness  may  supervene  a  day  or  two  before 

the    fatal    issue.      Aeiite   cases   of   pyemia   are   almost    uniformly    fatal.      A 
subacute  cases  ami  chronic  cases  recover  if  the  purulent  collections  are   few 
and  accessible,  s<>  that  they  can  lie  removed  or  evacuated.     Metastatic  foci  in 
the  liver,  lungs,  spleen,  brain,  or  kidney  are  more  dangerous  than  those  in  the 
muscles  ami  subcutaneous  ti-sues.     The  intensity  of  the  accompanyii  _ 
cemia  has  an  important  bearing  on  tin    prognosis. 

In  those  cases  following  chronic  suppurative  lesions — such  as  chronic  otitis 
media,  chronic  osteomyelitis  with  sinuses,  chronic  superficial  ulcerations — the 
history  and  the  presence  of  a  chronic  focus  of  suppuration  will  greatly  aid  in 
establishing  the  diagnosis.  In  certain  situations  it  may  he  possible  to  y. 
nize  inflamed  and  thrombotic  veins  ;l>  hard,  tender  cords  proceeding  from  the 
origin  of  the  infection  toward  the  heart.  Sometimes  the  venous  thrombosis  may 
give  rise  To  definite  signs  by  interference  with  the  circulation  of  the  part. 
Thus,  in  acute  osteomyelitis,  thrombosis;  of  the  deeper  veins  cans  -  -  illing 
of  the  limb  and  dilatation  of  the  superficial  veins  of  the  affected  extremity. 
Thrombosis  of  the  cavernous  sinu<  causes  bulging  of  the  eyeball  and  swelling 
and  edema  of  the  eyelids  and  conjunctiva. 

The  so-called  cases  «>f  cryptogenic  pyemia — i.  e.,  cases  in  which  the  original 
focus  of  infection  is  hidden  or  insignificant — present  certain  difficulties  in 
diagnosis.  A  careful  examination  should  be  made  of  the  nose,  mouth,  throat. 
ear-,  urethra,  bladder  and  prostate,  anus  and  rectum,  the  cutaneous  gnri 
the  lymph  glands  of  the  neck,  axilla;,  and  groins.  The  joints  should  be  care- 
fully inspected,  ami  palpated  for  -iuits  of  inflammation.  Points  of  tenderness 
should  be  sought  along  the  shafts  of  the  long  bones,  particularly  near  the 
epiphyseal  lines. 

Certain  diseases  should  be  excluded.  In  malaria  leucocytosis  is  absent. 
There  i<  often  a  malarial  history,  and  usually  the  malarial  organisms  may  be 
detected  in  the  blood.  The  spleen  may  he  found  notably  enlarged  in  l*>th 
conditions.  The  diseases  most  likely  to  be  confounded  with  pyemia — notably 
that  form  of  the  disease  complicating  suppurative  inflammation  of  the  middle 
ear — are  typhoid  fever  and  acute  miliary  tuberculosis. 

Malignant   endocarditis  may  closely   resemble   pyemia   with   numerous   vis- 
ceral metastases.     The  presence  of  endocardia]  murmurs  and  the  absent 
Bigns  of  metastasis  may  he  the  only  means  of  differentiation. 


118      DISEASES    CAUSED   BY   THE   PUS-PRODUCING   BACTERIA 


Differential  Diagnosis. — Hessler  has  prepared  a  table  intended  to  dif- 
ferentiate these  conditions.  To  this  table  must,  of  course,  be  added  leucocy- 
tosis,  or  at  least  a  high  polynuclear  count  in  pyemia.     It  is  here  quoted: 


Symptoms. 
Beginning: 


Running  from 
the  ear: 


Chills: 


Temperature: 


Sensorium: 


Headache: 


Vomiting: 


Delirium: 


Lung  symp- 
toms: 


Metastases: 


Appetite: 
Tongue: 


Otogenic  Pyemia. 

Sudden,  with  severe  head 
symptoms  —  dizziness, 
vomiting,  headache. 


Has  always  preceded. 


Frequently  recurring  after 
variable  intervals,  fol- 
lowed by  sweats. 

Highly  variable,  atypical, 
going  above  41°  C. ; 
often  subnormal. 


For  the  most  part  not 
influenced  in  typical 
cases;  disturbances  as 
a  result  of  headache, 
alternating  with  or  fol- 
lowing delirium. 

Severe,  one-sided,  varia- 
ble near  the  ear  and 
occiput.  Increases  with 
pressure  on  the  neck 
(MacEwen). 

Frequent,  often  recurring 
with  the  other  signs  of 
brain  irritation. 

Frequent,  varying  with 
other  brain  symptoms, 
increasing  in  children 
to  convulsions. 

Rapidly  transitory,  scarce- 
ly to  be  demonstrated, 
varying  between  bron- 
chitis, metastatic  ab- 
scesses with  pleurisy, 
and   pyopneumothorax. 

Especially  frequent  in  the 
lungs,  rare  in  the  liver, 
in  all  organs  of  the  body. 

Good  at  first,  then  absent. 

In  mild  cases  not  coated. 


Typhoid  Fevee. 

Begins  with  progressive 
prodromal  symptoms, 
disorders  of  the  general 
condition,  only  rarely 
(Liebermeister)  with  a 
chill  and  elevation  of 
temperature  to  40°  C. 

Accidental  complication, 
occurs  for  the  first  time 
in  the  fourth  or  fifth 
week. 

Rare. 


According  to  Wunderlich 
intermittent,  slowly  ris- 
ing and  falling.  Ab- 
sence of  temperature 
elevation  rare. 

Is  increasingly  disturbed 
at  the  end  of  the  first 
week ;  later,  mutter- 
ing combined  with  de- 
lirium. Picking  at  the 
bedclothes. 

Equally  distributed  over 
the  head,  without  chan- 
ging- 


Rare. 


More  bland. 


Usually  bilateral,  bron- 
chitic,  in  posterior  lower 
portions. 


Not  present. 


Slight. 

Dry,    coated,    protruded 
with  tremor. 


Acute  Miliary  and 
Meningeal  Tuber- 
culosis. 

Sudden  aggravation  of  an 
old  bronchial  catarrh, 
with  dull  headache  and 
depression. 


A    complication    of  lung 
tuberculosis. 


Often  at  beginning  a  sin- 
gle chill,  shiverings  fre- 
quent in  course  of  the 
disease. 

At  the  beginning  contin- 
uous at  a  moderate  ele- 
vation, later  hectic,  at 
last  subnormal,  often 
like  that  of  typhoid. 

Only  slight  delirium;  la- 
ter sopor  and  coma. 


Dull,  variable,  equal  on 
both  sides. 


Frequent,    especially    in 
meningeal  tuberculosis. 

Especially   in    meningeal 
tuberculosis. 


Breathing  disproportion- 
ately rapid,  increased 
to  orthopnea.  Sounds 
normal  or  only  large 
rales. 

Not  present. 


Slight, 

Usually  remains  moist. 


DISEASES   OF    WOUNDS 


L19 


S^  MFTOMS. 
Pulse: 

Course: 

A  bdorm  n : 
Roseola: 


Diarrhea: 

Abdominal 

pain: 

Spleen: 

Icterus: 

Death: 

Optic  neuri- 
tis: 

Blood  exami- 
nation: 


( >TOGENIC  Pi  EM  \. 

Hani,  full,  increased  fre- 
quency i"  chills  ami  fe- 
ver; disproportionate- 
ly high  in  sepsis. 

[rregular  in  the  intensity 
of  the  phenomena  ami 
in  duration. 

Rare  distention,  occurring 

after  I  he  second  week. 

Lacking;  bui  we  find  ele- 
vated red  (leeks  not  dis- 
appearing on  pressure. 


In  severe  cases,  toward 
the  end,  then  watery, 
profuse,  fetid. 

Frequent  over  lower 
spleen  when  metastases 
are  present. 

Almost  without  exception 
enlarged   and   palpable. 

Frequent,  in  mild  cases 
not  with  certainty. 

In  coma,  usually  by  em- 
bolism of  lungs. 

Often  very  clearly  pres- 
ent, rarely  septic  retinal 
hemorrhage. 

Gives,  when  positive,  dif- 
ferent kinds  of  micro- 
organisms (streptococci 
and  staphylococci). 


Typhoid  Feveb. 

Hard  and  full,  later  soft, 

dicrotic,  80  LOO,  paral- 
lel with  temperature. 


\<  i  i  i        Mii.i  \m        sm) 
Mi. \r.<. i.  si.       Tl  BEB- 

(  i  1...-1- 

I  disproportionately  high; 

120-150, SOfl  and  -mall. 


Not  especially  distended. 

Lacking. 


Characteristic      tempera-      Irregular,   la-tin::   I 
tun  curve  over  period        three  weeks. 

of   three   to  four  weeks. 

Frequently  distended  in 

the  Second  week. 

Characteristic  roseola   in 

Second  week,  especially 
in  the  lower  breast  and 
abdominal  region,  not 
sensitive  on  pressure, 
often  elevated 
Characterist  ic  pea-soup 
stools. 


( >nly  in  simultaneous  in- 
testinal tuberculot 


Ileocecal  pain  in  the  sec-  Usually  lacking. 
ond  week. 

Constantly    swollen    and  As    a    rule,    moderately 

palpable.  swollen. 

Rare.  Rare. 


In  coma,  with  heart-fail- 
ure. 
Not  present. 


Only  typhoid  bacillus. 


In  coma,  or  collaji.se  with 
failure  of  lungs  or  brain. 

Not  present,  choroidal 
tubercles  frequently  de- 
monstrable. 

Frequently  tubercle  ba- 
cilli. 


CHAPTER,    III 

SPECIAL   DISEASES   OF  WOUNDS 

ERYSIPELAS 

Erysipelas  is  an  acute  inflammation  of  the  skin  and  subcutaneous  tissues 
and  of  the  mucous  membranes,  characterized  by  a  sudden  onset,  a  tendency  to 
spread  slowly  or  rapidly  along  the  surface,  rarely  into  the  deeper  tissues,  and 
a  self-limited  course  of  variable  duration,  usually  with  complete  restitutio  ad 
integrum  of  the  affected  tissues.  Suppuration  is  infrequent.  The  disease  is 
usually  attended  by  marked  constitutional  symptoms,  including  fever.  Ery- 
sipelas is  caused  by  the  inoculation  of  a  wound  or  abrasion  of  the  skin  or 
mucous  membrane  with  the  Streptococcus  erysipelatis,  probably  identical  with, 
or  a  variety  of,  the  Streptococcus  pyogenes,  and  possessing  the  same  gross  and 
microscopic  appearances  as  well  as  identical  behavior  in  nutrient  media.  The 
cocci  occur  in  chains,  single  pairs  of  cocci  forming  the  links  of  the  chain. 
Single  cocci  are  from  0.3  to  0.4  p  in  diameter.  The  Streptococcus  pyogenes 
may  be  stained  with  any  of  the  anilin  colors  and  by  Gram's  method.  If  in- 
oculated into  the  ear  of  a  rabbit,  a  local  erysipelatous  process  is  produced. 
The  cocci  can  be  demonstrated  in  the  lymph  spaces  and  lymph  canals  of  the 
affected  tissues,  in  the  protoplasm  of  the  tissue  cells,  and  in  the  blood  capil- 
laries as  well  as  in  the  contents  of  the  vesicles  which  form  upon  the  skin 
surface.  The  germs  are  most  abundant  in  the  advancing  border  of  the  inflam- 
mation ;  they  are  usually  absent  from  the  tissues  where  the  process  has  existed 
for  several  days,  but  are  found  in  the  healthy-looking  skin  beyond  the  advanc- 
ing border.  The  inoculation  of  the  disease  may  take  place  in  a  wound,  clean 
or  infected,  during  any  stage  of  the  healing  process,  or  in  ulcers  of  any  de- 
scription.    The  period  of  incubation  is  short — twelve  to  forty-eight  hours. 

Onset  of  the  Disease. — In  some  cases  the  local  lesion  and  the  constitutional 
symptoms  appear  together.  In  others  the  disease  begins  with  prodromata, 
often  with  a  chill  and  a  rapid  rise  of  temperature  to  103°-105°  F.  There  is 
disturbance  of  the  stomach,  sometimes  vomiting,  and  pain  in  the  epigastrium ; 
the  tongue  is  coated;  headache  and  prostration  are  common.  A  leucocytosis 
of  from  12,000  to  20,000  is  commonly  present  during  severe  cases  of  erysipelas. 
In  mild  cases  the  leucocyte  count  is  usually  lower — 7,000-8,000  (Hayem). 
Relative  increase  in  the  polymorphonuclear  forms  is  the  rule.  When  suppura- 
tion occurs  the  leucocytes  may  suddenly  rise  in  number  to  a  high  grade — 
120 


ERYSIPELAS  |_M 

89,600  (Reinert),  59,400  (Epstein).     Leucocytosis  generally  varies  directly 
with  the  iVvcr,  Inii  may  be  entirely  absent  even  when  the  fever  is  high.     Bac 
teria]  examinations  of  the  blood  have  generally  been  uegative,  bu1  ;i  few  positive 
results  have  been  obtained  in  Bevere  casee  of  erysipelas—  notably  «>i  the  phleg 
nummis  type. 

The  local  lesion  follows  infection  in  twelve  to  forty-eight  hours.  Near  the 
site  of  the  inoculation  the  skin  becomes  brighl  red  in  color,  ;it  firsl  in  -pot-: 
(lie  spots  soon  coalesce,  and  ;i  uniform  red  area  is  produced  which  slowly  or 
rapidly  increases  in  size.  The  inflamed  skin  is  swollen,  a  little  elevated,  edem- 
atous, hot,  and  moderately  tender.  The  subjective  symptoms  of  burning  and 
itching  are  present.     Pain  is  usually  not  marked.     The  red  border  advances  in 

an  irregular,  wavy  line,  having  a  contour  which  has  been  likened  to  the  ad- 
vancement of  the  tire  in  a  piece  of  burning  paper.  The  redness  is  commonly 
of  a  bright,  vivid  quality,  in  some  cases  tinged  with  yellow,  in  others  the  red- 
ness may  become  dusky,  almost  purple.  Vesicles  form  upon  the  surface  con- 
taining (dear  serum;  Later  the  serum  becomes  cloudy,  and  the  vesicles  dry  up, 
forming  crusts.  In  some  cases  the  vesicles  coalesce  into  lariie  blebs  (erysipelas 
bullosum).  In  facial  erysipelas,  swelling  of  the  eyelids,  ears,  and  lips  is  often 
very  great.  The  disease  progresses  alon»-  the  surface  in  a  very  irregular  man 
ner — sometimes  fast,  sometimes  slow — the  redness  fades  in  one  part  while 
advancing  in  another.  A  new  focus  of  inflammation  may  suddenly  appear 
in  a  distant  pari  of  the  body.  The  disease  rarely  lasts  longer  than  fourteen 
davs,  but  relapses  are  common,  and  a  part  from  which  the  disease  has  dis- 
appeared may  be  reinfected.  Desquamation  regularly  follows.  (For  a  de- 
scription of  erysipelas  of  the  inncous  membranes,  sec  Erysipelas  of  the  Face.  | 

Constitutional  Symptoms — The  gravity  of  the  constitutional  symptoms  cor- 
responds usually  with  the  extent  and  severity  of  the  local  lesion.  The  more 
severe  constitutional  symptoms  often  occur  in  erysipelas  of  the  face  and  head. 
They  are  often  grave,  notably  in  those  debilitated  by  bad  hygienic  conditions 
and  by  drink.  The  fever  is  often  high;  the  temperature  is  continuous,  remit- 
tent, or  intermittent,  or  quite  irregular.  Severe  headache  is  usual  in  cases 
of  facial  erysipelas,  and  delirium,  sometimes  of  a  furious  character,  occurs, 
notably  in  chronic  alcoholics.  Unfavorable  symptoms  are  vomiting  and  diar- 
rhea— sometimes  of  a  bloody  character — delirium,  stupor,  and  coma.  Fading 
of  the  eruption  is  usually  followed  by  immediate  subsidence  of  the  fever. 

A  wound  infected  with  erysipelas  may  undergo  little  or  no  change  in  ap- 
pearance. Primary  union,  even,  may  not  be  interfered  with.  A  granulating 
wound  may  be  unchanged  or  the  granulations  may  become  pale  and  flabby,  or 
become  covered  with  a  diphtheritic  membrane.  Only  in  bad  forms  of  erysipe- 
las— notably  in  the  cases  of  phlegmonous  and  gangrenous  erysipelas  do  the 
wound  edges  become  necrotic.  Swelling  and  tenderness  of  the  communicating 
lymphatic  glands  are  regularly  present,  often  very  early  in  the  disease.  Occa- 
sionally the  inflammation  of  the  glands  may  be  followed  by  purulent  softening 
and  abscess. 


122  SPECIAL  DISEASES    OF   WOUNDS 

Complications  of  Erysipelas. — The  complications  are  numerous  and  varied. 
Localized  subcutaneous  abscesses  may  occur;  they  are  often  characterized  by 
rather  a  subacute  course.  There  will  be  formed  one  or  many  subcutaneous 
swellings,  without  redness  of  the  overlying  skin.  Moderate  pain  and  tender- 
ness with  distinct  signs  of  fluctuation  will  be  noted.  Diffuse  and  progressive 
necrosis  and  purulent  softening  of  the  subcutaneous  tissues  may  occur,  accom- 
panied sometimes  by  widespread  sloughing,  and  even  by  putrid  decomposition 
of  the  subcutaneous  tissues,  and  of  the  loose  connective  tissue  of  the  inter- 
muscular planes,  and  even  of  the  skin  itself  (Erysipelas  phlegmonosum,  Ery- 
sipelas gangrenosum).  In  these  cases  there  will  be  profound  constitutional 
depression  and  marked  local  swelling,  but  redness  of  the  skin  may  be  absent 
until  the  skin  is  about  to  be  perforated.  If  the  process  involves  the  skin  at  the 
start  a  hard  and  brawny  swelling  will  be  produced;  the  skin  will  be  red,  or 
dark  red,  or  even  purple  in  color.  During  the  earlier  stages  of  the  process, 
while  the  inflamed  skin  or  subcutaneous  tissues  are  undergoing  necrosis,  there 
may  be  no  pus  at  all,  and  the  signs  of  fluctuation  will  be  absent.  If  an  incision 
be  made  into  the  part  at  this  time,  a  hard  edema  of  the  skin  and  subcutaneous 
tissues  will  be  noted.  The  smaller  blood-vessels  will  bleed  but  little,  or  not  at 
all,  and  the  necrotic  tissues  will  resemble  bacon — both  in  appearance  and  con- 
sistency. If  incised  at  a  later  period,  after  purulent  softening  has  occurred, 
the  subcutaneous  tissues  appear  as  yellowish,  sloughing,  spongy  masses,  some- 
times having  a  putrid  odor,  from  which  a  thin  and  watery  pus  exudes.  Addi- 
tional infection  with  gasogenic  bacteria  produces  swelling  and  the  character- 
istic crackling  of  the  tissues  upon  pressure,  as  well  as  transmitting  a  sensation 
of  crepitation  to  the  fingers. 

The  complications  affecting  the  contents  of  the  skull  are  sinus  phlebitis, 
meningitis,  and  pyemia  (see  Head).  Pyemia  is  to  be  recognized  by  the  char- 
acteristic chills,  followed  by  a  rapid  rise  of  temperature,  as  sudden  a  decline 
to  normal  or  below,  followed  by  sweating  and  by  the  formation  of  pyemic 
abscesses  (see  Pyemia).  Pleurisy  and  pneumonia  occur,  and  are  to  be  recog- 
nized by  their  physical  signs.  Pericarditis  and  endocarditis  are  occasional 
complications.  Acute  nephritis  is  not  uncommon,  to  be  recognized  by  the  char- 
acteristic changes  in  the  urine,  a  diminished  quantity  of  urine,  and  the  pres- 
ence of  albumin,  casts,  and  blood  cells.  Peripheral  neuritis  and  neuralgias 
may  be  sequelae  of  erysipelas. 

TETANUS 

Tetanus  is  a  disease  caused  by  the  inoculation  of  a  wound  with  tetanus 
bacilli.  The  tetanus  bacillus  is  a  rod-shaped  germ  4  to  5  ^  in  length,  with 
rounded  ends.  The  bacillus  forms  spores.  An  enlargement  occurs  at  one  end 
of  the  rod,  forming  a  rounded  knob,  giving  the  organism  somewhat  of  a  battle- 
dore shape.  The  enlarged  end  is  three  or  four  times  the  diameter  of  the  rod 
itself.     The  rods  may  be  found  singly  or  in  threads.     The  bacilli  possess  motil- 


TKTANTS  123 

ity,  and  cilia  may  I"'  demonstrated  by  proper  staining.  The  cilia  may  occur 
;ii  the  ends  of  the  rods  or  from  various  points.  The  tetanus  bacillus  is  anae 
robic,  and  cannol  be  cultivated  in  the  presence  of  oxygen  upon  ordinary  plate 
cultures.  In  order  to  determine  the  presence  of  the  bacilli  in  ;i  Buspected  caa 
of  tetanus  the  discharge  from  the  wound  may  be  stained  with  gentian  violet, 
methylene  blue,  <>r  other  anilin  Btain.  A  recognition  of  the  spore-producing 
battledore  tonus  is  necessary  for  ;i  microscopical  diagnosis;  if  this  fails,  deep 
cultures  may  be  made  in  glucose  gelatin  for  thirty  hours  al  the  body  tempera- 
ture, :in<l  the  culture  examined  for  spore-bearing  bacilli,  [noculation  experi- 
ments upon  mice  and  guinea  pigs  may  also  be  tried.     (!!.('.  Ernst,  loc.  cit.) 

The  germ  is  found  in  the  tissues  al  or  near  the  site  of  inoculation,  but  it 
lias  not  been  demonstrated  in  the  blood  or  in  distant  organs,  except  in  very 
rare  instances.  Il  is  supposed  thai  the  symptoms  of  i he  disease  are  caused 
chiefly  by  the  absorption  of  the  poisonous  products  accompanying  the  growth 
of  I  he  bacilli  at  or  near  the  point  of  inoculation.  The  poison  seems  to  exerl 
its  influence  chiefly  upon  the  central  nervous  system,  and  through  the  medium 
of  the  peripheral  nerves  upon  the  muscles.  There  are  no  characteristic  lesions 
of  tetanus  found  after  death.  Punctate  hemorrhages  have  been  found  in  the 
brain  of  men  and  animals  after  death  from  tetanus,  and  changes  have  been 
described  in  the  medulla  and  in  the  cord,  as  well  as  in  the  peripheral  nerves, 
but  they  do  not  appear  to  be  constant. 

Tetanus  follows  punctured  wounds  and  contused  and  lacerated  wounds  of 
I  he  deeper  tissues,  rather  than  superficial  wounds,  as  mighl  be  expected  from 
the  anaerobic  habits  of  the  organism,  but.  superficial  abrasions  are  not  exempt 
from  infection,  a  mere  scratch  of  the  forearm  having  been  followed  by  tetanus 
in  one  of  my  own  cases,  as  well  as  in  other  cases  reported.  The  natural  habitat 
of  the  tetanus  germ  is  the  soil;  certain  localities  appear  to  be  favorable  for 
its  occurrence — for  example,  the  soil  of  certain  streets  in  the  city  of  New 
York  has  been  found  to  contain  numerous  tetanus  germs  from  time  to  time, 
and  certain  districts  on  Long  Island  are  said  to  furnish  an  unusual  number 
of  cases  of  tetanus.  In  tropical  countries  the  disease  appears  to  be  more  com- 
mon, and  of  a  more  severe  type.  Wounds  of  the  hands  and  i'vei  appear  to  be 
Inoculated  with  tetanus  more  often  than  wounds  in  other  regions.  Such  wounds 
are  more  apt  to  be  contaminated  with  the  soil,  and  it  is  probable  that  the  inocu- 
lation may  often  occur  from  the  contaminated  skin  in  a  certain  proportion  of 
cases  rather  than  from  the  instrument  creating  the  wound.  Wounds  of  the 
hand  produced  by  the  wadding  from  toy  pistols  have  been  followed  iu  the  city 
of  New  York  by  tetanus  in  quite  a  large  number  of  cases.  Following  the  cele- 
bration of  the  Fourth  of  duly  in  this  city,  a  considerable  number  of  eases 
annually  occur  from  wounds  of  this  character  upon  the  hands  of  boys.  Putrid 
organic  materials  and  the  feces  of  the  herbivorous  animals  often  contain  the 
germs  of  tetanus. 

Acute  and  Chronic  Types  of  the  Disease. — Tetanus  is  usually  described  as 
occurring  in  an  acute  and   a  chronic   form,  but  no  definite  line  can  be  drawn 


124  SPECIAL  DISEASES   OF  WOUOTS 

between  the  two  types  of  the  disease.  (In  two  acute  cases  of  tetanus,  Cabot 
reports  a  leucocytosis  of  11,900  and  19,600,  respectively — Ewing.)  It  has 
been  noted  that  a  large  proportion  of  those  cases  of  tetanus  which  develop 
within  a  week  or  ten  days  from  the  time  of  inoculation  run  a  severe  and  usually 
rapid  course,  and  end  in  death  in  a  large  proportion  of  cases.  In  those  cases 
developing  later  than  fourteen  days  from  the  time  of  inoculation  the  type  of 
the  disease  is  less  severe,  and  a  large  proportion  of  them  recover  independently 
of  the  character  of  the  treatment. 

Invasion  of  the  Disease. — The  first  symptoms  of  an  attack  of  acute 
tetanus  are  usually  stiffness  of  the  muscles  of  the  lower  jaw  and  of  the  neck, 
sometimes  difficulty  in  swallowing,  sometimes  stiffness  of  the  muscles  of  the 
wounded  limb.  The  contraction  of  the  masseter  muscles  is  usually  marked, 
and  within  a  few  hours  the  mouth  can  only  be  opened  with  difficulty,  if  at 
all.  Painful  spasmodic  contractions  of  these  muscles  are  soon  added.  During 
the  next  twenty-four  hours  the  muscles  of  the  back  of  the  neck  become  con- 
tracted and  rigid,  and  later  all  the  muscles  of  the  back.  The  muscles  of  the 
front  of  the  abdomen  and  of  the  lower  extremities  are  next  affected.  The 
muscles  of  the  upper  extremities  are  usually  but  slightly  involved.  The  con- 
tractions of  the  muscles  are  tonic  in  character,  and  to  the  touch  they  feel  of  a 
boardlike  hardness.  When  the  disease  is  fully  developed  there  are  added  clonic 
spasms,  of  greater  or  less  severity,  brought  on  by  slight  sources  of  external  irri- 
tation.    Marked  opisthotonos  may  occur  during  these  attacks. 

Course  of  the  Disease. — After  twenty-four  hours  the  disease  is  usually 
fully  developed.  The  temperature,  which  was  normal  or  but  little  elevated  at 
the  onset,  rises  several  degrees.  The  patient  suffers  from  retention  of  urine. 
There  is  generally  from  time  to  time  profuse  sweating,  notably  after  the  occur- 
rence of  a  general  convulsion.  Attempts  at  swallowing  cause  a  marked  spasm 
of  the  muscles  of  deglutition  and  pain.  The  contracted  muscles  everywhere 
are  painful,  and  the  pain  is  greatly  increased  by  the  clonic  spasms.  The  mind 
usually  remains  clear  throughout  the  disease,  although  confusion  of  ideas  and 
even  delirium  are  not  uncommon  in  severe  cases  either  as  the  result  of  the 
disease  or  of  the  drugs  administered.  The  patient  is  unable  to  sleep ;  he  lies 
in  bed,  sometimes  upon  his  back,  sometimes  upon  his  side.  The  contraction 
of  the  muscles  of  the  face  produces  a  distorted  expression  of  the  countenance. 
The  eyelids  are  puckered  and  the  eyes  partly  closed.  The  nostrils  are  rather 
widely  opened.  The  lips  may  be  drawn  away  from  the  teeth,  producing  the 
appearance  known  as  the  sardonic  grin.  The  head  is  drawn  strongly  back- 
ward ;  there  is  a  deep  hollow  in  the  lumbar  region  of  the  back ;  the  lower  limbs 
are  rigidly  extended;  there  is  plantar  flexion  of  the  feet.  In  the  most  acute 
cases  of  tetanus  the  temperature  may  be  very  high.  The  temperature  is  usually 
continuous,  sometimes  with  moderate  remissions. 

A  fatal  result  may  occur  in  forty-eight  hours  or  less.  Patients  who  survive 
the  first  six  days  of  the  disease  have  a  better  chance  of  recovery.  Death  occurs 
from  exhaustion,  due  to  the  prolonged  and  violent  muscular  contractions,  to  the 


TKT.WI  s  L25 

inability  to  swallow  fond,  to  pain,  t<»  loss  of  Bleep,  and  occasionally  to  respiratory 
failure  during  ;i  general  clonic  convulsion.  If  the  patienl  is  to  survive,  the 
fever  diminishes;  the  clonic  muscular  spasms  become  less  marked,  and  cease; 
the  tonic  contractions  slowly  diminish  in  intensity;  sleep  becomes  possible; 
the  patient  is  able  to  swallow.  The  muscular  rigidity  ceases  in  the  extremities, 
and  later  in  the  muscles  of  the  back  and  trunk.  Convalescence  is  usually 
gradual,  and  the  contraction  of  the  muscles  affecting  the  jaws  may  exisl  for 
several  weeks.     Relapses  are  not  uncommon.     Severe  general  convulsions  and 

high  fever  are  of  had   prognostic  import. 

Subacute  and  Chronic  Tetanus. — The  subacute  and  chronic  cases  of  tetanus 
are  usually  developed  after  a  longer  period  of  incubation — from  ten  to  fifteen 
days,  or  even  more.  The  symptoms  are  like  in  kind  to  those  of  acute  tetanus, 
hut  less  severe.  In  these  cases  the  wound  may  be  already  healed,  or  it  may 
he  partly  healed  and  have  the  appearance  of  a  mild  infection.  If  healed,  the 
scar  may  be  somewhat  red,  swollen,  and  sensitive  on  pressure.  There  may 
he  moderate  fever  or,  in  the  chronic  cases,  none  at  all.  The  contraction  of 
the  museles  may  be  general,  or  confined  to  certain  groups  of  muscles.  The 
muscles  of  the  jaw  are  uniformly  contracted.  The  muscles  of  the  extremities 
may  escape,  and  the  spasms  may  be  confined  to  the  jaw,  some  of  the  muscles 
of  the  hack,  and  to  the  muscles  of  the  affected  limb.  Some  of  the  cases  of 
subacute  tetanus,  even  those  which  do  not  develop  for  a  fortnight  or  more, 
are  nevertheless  severe  in  character  and  fatal  in  their  results. 

Head  Tetanus  (Tetanus  hydrophobicus). — This  form  of  the  disease  follows 
wounds  inoculated  with  tetanus  germs  in  the  region  supplied  by  the  twelve 
pairs  of  cranial  nerves.  It  is  characterized  commonly  by  unilateral  paralysis 
of  the  muscles  supplied  by  the  facial  nerve,  and  by  notable  spasm  of  the 
muscles  of  deglutition.  Ptosis  is  usually  marked.  The  patient  is  unable  to 
swallow,  and  attempts  at  swallowing  arc  followed  by  spasmodic  contractions 
of  the  muscles  of  the  throat  (Tetanus  hydrophobicus).  The  mortality  is  -aid 
not  to  be  greater  than  in  cases  of  ordinary  tetanus. 

Differential  Diagnosis. — The  differential  diagnosis  between  tetanus  and  other 
conditions  should  not  he  difficult.  From  poisoning  by  strychnin  it  is  to  he 
distinguished  by  the  fact  that,  though  the  muscular  contractions  in  strychnin 
poisoning  are  tetanic  in  character,  complete  relaxation  of  the  muscles  occurs 
between  the  spasms;  nor  are  the  muscles  of  the  jaw  especially  affected  in 
strychnin  poisoning  more  than  others.  Lockjaw  is  absent.  In  strychnin 
poisoning  there  is  photophobia,  and  objects  are  seen  of  a  green  color.  The 
inflammatory  condition-  of  the  mouth,  neck,  and  throat,  which  lead  to  inability 
to  open  the  mouth,  are  usually  accompanied  by  a  definite  local  lesion  not 
difficult  to  recognize,  and  the  hard,  boardlike  condition  of  the  masseter  muscle- 
is  absent.  Inflammation  of  the  temporal  maxillary  articulation  is  attended  by 
local  pain  and  tenderness.  The  condition  known  as  tetany  hears  a  similarity 
to  tetanus  only  in  name.  This  disease  sometimes  follows  operations  upon  the 
thyroid  gland    (see  also  Gastric  Tetany).      A   nonfatal   condition  of  muscular 


126  SPECIAL   DISEASES    OF   WOUNDS 

contractions  somewhat  similar  to  tetany  may  occur  in  young  hysterical  and 
nervous  individuals.  The  symptoms  are  tonic  spasms  of  the  muscles  of  the 
upper  extremity,  rarely  the  lower.  Pressure  upon  the  nerve  trunk  supplying 
the  affected  muscles  produces  spasm  of  these  muscles  (Trousseau's  symptom). 
(See  Gastric  Tetany.) 

RABIES 

Synonyms. — Hydrophobia,  madness;  French,  La  Rage;  German,  Hunds- 
wuth,  Wuthkrankheit ;  Italian,  Rabbia,  Lyssa. 

Definition. — Rabies  is  an  acute,  contagious  disease,  produced  by  inoculation 
of  a  wound  with  a  specific  virus  contained  in  the  saliva  of  a  rabid  animal,  usu- 
ally transmitted  by  a  bite. 

The  exact  nature  of  the  infectious  agent  is  not  certainly  known,  but  that 
it  is  some  form  of  micro-organism  there  can  be  no  doubt. 

Rabies  in  Man. — In  man  the  disease  is  characterized  by  a  rather  long  period 
of  incubation,  by  extreme  mental  depression  and  anxiety,  by  the  occurrence  of 
violent  spasms  of  the  muscles  of  deglutition  and  respiration,  later  by  general 
convulsions,  delirium,  and  finally  by  paralysis,  exhaustion,  and  death.  All 
cases  end  fatally,  and  the  duration  of  the  disease  is  but  a  few  days.  Reported 
recoveries  are  few  and  doubtful. 

Animals  Affected. — All  mammals  and  birds  are  susceptible.  The  disease  is 
frequent  among  dogs,  and  the  dog  family  in  general,  is  less  common  among 
cats,  and  is  occasionally  observed  among  cattle,  sheep,  and  pigs,  rarely  in 
horses. 

Distribution. — Rabies  occurs  in  all  civilized  parts  of  the  world  except  in 
Australia,  where  it  has  been  kept  out  by  strict  quarantine.  Of  the  countries 
of  Continental  Europe,  it  is  very  frequent  in  Russia ;  has  become  rare  in 
Germany,  JSTorway,  Sweden,  Denmark,  and  Switzerland.  It  is  rare  in  Eng- 
land, and  is  fairly  common  in  the  United  States.  In  those  countries  where 
the  disease  is  .now  infrequent  it  has  been  held  in  check  by  strictly  enforcing 
the  muzzling  of  dogs.  Hydrophobia  from  the  bites  of  animals  other  than  the 
dog  is  relatively  rare  in  all  countries,  though  a  moderate  number  of  cases 
occur  in  Russia  from  the  bites  of  rabid  wolves.  The  danger  of  bites  from 
rabid  animals  varies  with  the  extent  and  situation  of  the  wounds  and  with 
the  species  of  animal.  Severe  lacerated  wounds  and  wounds  of  regions  richly 
supplied  with  nerves — the  face  and  hands — are  more  dangerous  than  wounds 
of  the  lower  limbs  and  trunk.  This  is  partly  owing  to  the  protection  afforded 
by  clothing,  since  much  of  the  virus  contained  in  the  saliva  remains  on  the 
cloth,  the  teeth  being  rendered  comparatively  clean.  Bites  involving  large 
nerve  trunks  anywhere  in  the  body  are  particularly  dangerous.  It  has  also 
been  observed  that  dogs  and  other  animals  with  long  thick  hair  are  less  apt 
to  be  infected  than  are  animals  with  short  hair,  or  those  from  whom  the  hair 
has  been  cut  away.     While  the  largest  number  of  cases  follow  bites  by  dogs, 


RABIES  127 

bites  by  wolves  and  cats  are  more  dangerous.  While  deep  wounds  are  more 
npi  to  be  followed  by  the  disease,  -till  inoculation  may  occur  upon  abraded 
surfaces.  as  from  licking  by  a  pel  animal,  ;im<I  the  disease  has  followed  inocu- 
lation while  performing  autopsies  upon  the  bodies  of  men  and  animal-  dead 
of  the  disease.  Men  arc  more  likely  to  contrad  hydrophobia  than  women, 
partly  owing  to  their  mode  of  life  and  partly  to  the  protection  afforded  by 
sl<iris  ami  petticoats.  Two  fifths  of  all  cases  of  hydrophobia  occur  in  children 
less  than  fifteen  years  of  age,  and  many  of  the  bites  are  upon  the  head,  neck, 
and  face.  This  is  owing  to  their  use  of  the  streets  a-  a  playground,  to  their 
ignorance  of  danger,  and  to  their  weakness  and  consequent  inability  to  fight 

off  a  rabid  dog.  What  proportion  of  hires  by  rahid  animals  an-  followed  by 
hydrophobia  it  is  not  easy  to  say:  probably  less  than  half.  The  statistics  given 
van  from  L6.6  per  cenl  by  Leblanc  to  more  than  fifty  per  cenl  (Bouley). 
Among  :.'»'>(*>  persons  bitten,  collected  and  reported  by  Bouley,  then-  were  152 
deaths.  Of  these,  120  were  bitten  on  th<-  face  and  hand-.  The  mortality  fol- 
lowing; the  bites  of  rahid  wolves  has  been  estimated  at  from  sixty  to  eighty 
pel-  cent.  More  cases  of  hydrophobia  occur  in  the  Bpring  and  summer  months 
than  during  the  rest  of  the  year. 

Nature  and  Distribution  of  the  Contagion. — From  it-  behavior  we  know  that 
rallies  must  he  due  to  some  specific  organism,  hut  as  yet  no  one  has  been  able 
to  recognize  or  isolate  it  with  certainty.  The  disease  hears  a  striking  analogy 
to  tetanus,  since  in  its  distribution  the  virus  follows  the  peripheral  nerv<  - 
the  central  nervous  system.  The  virus  is  found  in  all  parts  of  the  nervous 
system  after  death,  but  is  most  abundant  and  produces  the  most  marked  micro- 
scopic changes  in  the  medulla.  The  passage  of  the  virus  from  the  point  of 
inoculation  to  the  medulla  may  be  prevented  by  severing  the  spinal  cord,  as 
proven  by  experiment.  The  saliva  and  the  salivary  glands  contain  the  virus, 
and  in  the  saliva  the  virus  is  present  for  a  day  or  two  before  the  symptoms 
of  the  disease  are  manifest.  The  pancreas  and  suprarenal  capsule  may  contain 
the  virus,  as  may  also  the  milk.  The  blood,  the  muscles,  and  the  lymphatic 
glands  are  innocuous.  The  virus,  when  filtered  through  plaster  and  injected 
into,  animals,  produces  a  toxemia  with  nervous  symptoms  resembling  the  dis- 
ease itself.  The  virus  is  destroyed  by  light,  by  drying,  and  by  heat.  Tn'r.-ct 
Bunlight  destroys  it  in  about  forty  hours.  Water  preserves  it.  and  in  glycerin 
it  may  he  kept  almost  indefinitely.  When  dried  in  the  air,  protected  from 
light  and  putrefaction,  it  gradually  loses  its  virulence,  and  at  the  end  of  fifteen 
days  becomes  harmless,  this  being  the  method,  now  in  general  use,  used  by 
PasteiO  in  preparing  his  material  for  protective  inoculation.  The  virus  i<  not 
injured  by  cold,  and  may  remain  active  in  the  bodies  of  animals  buried  in  the 
ground  for  many  days.  Tt  is  quickly  destroyed  by  1—1,000  EEgcl2  solution, 
and  by  formalin.  It  loses  its  virulence  almost  immediately  when  mixed  with 
an  equal  quantity  of  bile. 

Incubation. — The  period  of  incubation   in   man  varies  within  wide  limits. 
The  shortest  period  has  been  twelve  days.     The  longesl  i-  not  definitely  known. 


128  SPECIAL   DISEASES    OF   WOUNDS 

It  is  certainly  as  much  as  a  year,  and  may  be  longer.  The  average  is  forty 
clays.  It  is  unusual  for  the  disease  to  develop  after  three  months,  and  rare 
after  six  months. 

Pathology. — There  are  no  gross  pathological  changes  characteristic  of  rabies 
found  after  death  in  either  men  or  animals.  In  man  the  blood  remains  fluid 
after  death,  and  is  dark  in  color.  Congestion  of  the  throat,  gullet,  and  stomach 
are  common.  There  may  be  congestion  of  the  lungs,  with  emphysema.  The 
brain  and  its  meninges  are  often  congested.  In  dogs  similar  lesions  are  ob- 
served, but  the  most  characteristic  finding,  and  one  which  furnishes  strong- 
corroborative  evidence  in  a  suspicious  case,  is  the  absence  in  the  stomach  of 
food  and  the  presence  of  foreign  material — wood,  straw,  grass,  hair,  wool,  and 
the  like.     Such  are  found  in  ninety  per  cent  of  the  cases. 

Postmortem  Diagnosis. — The  most  valuable  means  of  diagnosis  is  by  the 
microscopic  examination  of  portions  of  the  nervous  system.  When  a  human 
being  has  been  bitten  by  an  animal  suspected  of  rabies  it  is  important  to  know 
whether  the  animal  was  actually  rabid  in  order  that  preventive  treatment  may 
be  commenced  at  once.  Formerly  the  only  certain  means  of  diagnosis  was  by 
inoculating  an  animal,  usually  a  rabbit,  with  some  of  the  medulla  of  the  dog 
supposed  to  have  been  mad.  The  inoculations  were  made  beneath  the  dura 
of  the  rabbit  in  order  to  produce  the  most  active  infection  and  the  shortest 
period  of  incubation,  but  this  period,  being  from  sixteen  to  twenty  days  or 
more,  was  too  long  to  be  useful,  since  it  has  been  found  by  experience  that  in 
order  to  procure  adequate  protection  the  preventive  inoculations  must  be  made 
within  one  week  of  the  receipt  of  the  bite.  At  the  present  time  microscopic 
examination  of  portions  of  the  nervous  system  of  an  animal  dead  of  rabies 
furnishes  data  which  are  conclusive,  so  that  a  positive  diagnosis  is  now  possible 
within  from  twenty-four  to  seventy-two  hours.  The  animal  should  be  allowed 
to  die  of  the  disease,  since  if  killed  the  microscopical  appearances  sought  for 
may  be  absent. 

The  work  of  Van  Gehuchten,  ISTelis,  and  ISfegri  have  rendered  a  microscopic 
diagnosis  possible.  The  details  of  the  two  methods  given  below  are  from 
Ravenel,  in  Osier's  "  Modern  Medicine,"  vol.  iii,  page  57  et  seq. : 

Van  Gehuchten  and  Nelis  believe  that  the  virus  acts  by  preference  on  the 
peripheral  cerebrospinal  and  sympathetic  ganglia.  The  most  constant  and  marked 
lesions  are  found  in  the  intervertebral  and  the  pneumogastric  ganglia.  They  con- 
sist of  the  atrophy,  the  invasion,  and  the  destruction  of  the  nerve  cells  by  new- 
formed  cells,  due  to  the  proliferation  of  the  cells  of  the  endothelial  capsule.  The 
new-formed  cells  increase  in  number,  invade  the  protoplasm  of  the  nerve  cell, 
and  finally  occupy  the  entire  capsule,  the  nerve  cell  proper  having  completely  dis- 
appeared, while  in  its  place  is  seen  a  mass  of  round  cells.  The  nerve  cells  which 
are  not  destroyed  may  show  various  degenerative  changes  of  the  protoplasm  and 
nuclei,  such  as  vacuolation,  eccentricity  of  the  nuclei,  chromatolysis,  etc.  In 
advanced  cases  practically  all  the  nerve  cells  may  be  destroyed,  and  the  section 
has  much  the  appearance  of  an  alveolar  sarcoma.     These  changes  have  been  found 


■RAP.TES  129 

in  a  greal  variety  of  animals.  They  axe  besl  observed  In  dogs  and  cows,  bul  are 
quite  characterisl  ic  in  .-ill  animals  studied. 

In  L903,  Negri  announced  the  discovery  of  certain  bodies  in  the  nerve  cells 
of  rabid  animals.  They  are  found  especially  in  the  born  of  Amnion.  They  are 
from  I  to  23  /<  in  diameter,  oval,  round  or  triangular  in  shape,  according  to  their 
size  and  position  in  the  cell.    They  are  strongly  eosinophilic. 

The  Negri  bodies  are  described  as  consisting  of  a  fundamental  Bubstance,  which 
is  homogeneous,  aongranular,  and  hyaline  in  appearance,  resembling  coagulated 
albumin.  Within  them  are  clear  shining  areas,  which  at  firsl  Bight  appear  to  be 
vacuoles,  but  under  higher  powers  show  one  or  more  points  of  deeper  color.  They 
arc  quite  rc-istant  to  external  agencies,  remaining  unchanged  for  a  long  time  by 
putrefaction,  desiccation  (one  hundred  and  eighty-three  days),  etc.  Material  may 
be  preserved  in  glycerin  for  eighty  days  without  altering  the  Negri  bodies.  They 
are  destroyed  by  thirty-three  per  cent  solution  of  caustic  potash. 

They  are  well  brought  out  by  dilute  solutions  of  acetic  acid  or  by  ten  per  cent 
osmic  acid,  or  by  immersion  in  thirty-three  per  cent  alcohol  for  forty-eight  hours, 
or  by  staining  after  the  method  of  Mann  or  Romanowsky.  They  are  especially 
numerous  and  large  in  cases  of  rabies  of  long  incubation  period  (Negri).  They 
are  best  developed  in  the  horn  of  Amnion,  less  in  the  cells  of  Purkinje,  and  less 
still  in  the  spinal  ganglia  and  vagus. 

The  nature  of  the  bodies  is  unknown.  Negri  believes  them  to  be  protozoa,  and 
considers  them  the  causative  agents  of  the  disease.  Yalentie  reports  that  the  virus 
of  rahies  is  neutralized  in  the  test-tubes  as  well  as  the  living  body  by  quinine,  while 
no  other  alkaloid  was  found  which  had  this  power.  This  is  held  as  strong  evidence 
of  the  protozoan  nature  of  the  bodies. 

Babes  has  made  an  exhaustive  study  of  the  matter  and  confirms  the  practically 
constant  presence  of  Xegri  bodies  in  the  brain  in  rahies.  although  he  does  not 
consider  them  the  actual  parasite,  hut  rather  evidence  of  the  resistance  on  the 
part  of  the  cell,  by  which  it  is  able  to  englobe  and  encapsulate  the  invading  organ- 
ism, lie  believes  the  fine  round  granules  coloring  a  blue  or  black  with  the  Cajal- 
Griemsa  stain  to  be  the  parasite  in  its  active  state.  These  granules  are  found  exclu- 
sively in  the  protoplasm  of  the  degenerated  nerve  cells  in  the  most  severely  involved 
areas  of  the  nervous  system,  whereas  the  Xegri  bodies  occur  in  cells  hut  little 
altered  and  having  no  close  connection  with  the  symptoms,  lie  believes  the  Xegri 
bodies  to  he  encapsulated  parasites  undergoing  involution  or  degeneration. 

For  diagnosis  by  the  method  of  Van  Gehuchten  and  Xelis,  the  plexiform  gan- 
glion of  the  pneumogastric  nerve  is  selected,  as  it  is  easily  dissected  out.  and  pre- 
sents the  characteristic  changes  in  the  ganglion  cells.  In  dogs,  the  ganglion  is 
readily  found  by  cutting  down  on  the  pneumogastric  nerve  in  the  neck,  and  follow- 
ing it  up.  Near  the  skull  it  divides  into  two  branches,  on  one  of  which  (the 
smaller)  is  found  a  small,  oval,  reddish  ganglion,  the  cervical.  The  larger  branch 
enters  the  plexiform  ganglion,  which  is  easily  recognized  by  its  fusiform  shape  and 
white  or  grayish  color.  It  is  seldom  more  than  a  half  inch  from  the  foramen,  and 
it  is  generally  necessary  to  cut  the  nerve  as  it  emerges  from  the  skull.  The  ganglion 
may  he  prepared  \'ov  section  by  any  of  the  rapid  methods. 

The  best  stain  for  general  use  is  hemalum  (Gruber),  made  up  with  a  0.5  per 
cent  solution  of  carbolic  acid,  and  counter  stained  with  eosin.  This  method  has 
10 


130  SPECIAL  DISEASES    OF   WOUNDS 

been  in  nse  at  the  laboratory  of  the  State  Live  Stock  Sanitary  Board  of  Pennsyl- 
vania for  five  years,  and  has  been  found  most  satisfactory.  A  large  number  of 
cases  have  been  controlled  by  inoculation,  and  no  error  has  yet  been  found.  While 
the  lesions  cannot  be  considered  specific,  since  similar  changes  have  been  noted 
occasionally  in  other  toxic  conditions,  and  in  the  ganglia  of  aged  dogs,  yet  by 
their  extent  and  constant  occurrence  in  rabies  they  have  an  unquestionable  sig- 
nificance, and,  taken  in  connection  with  even  a  meager  history,  have  an  absolute 
diagnostic  value. 

Certain  precautions  must  be  observed:  The  animal  must  be  allowed  to  die  of 
the  disease.  The  lesions  may  be  slight  or  entirely  wanting  in  animals  killed  pre- 
maturely, and  in  such  cases  their  absence  does  not  preclude  the  existence  of  rabies. 
If  absent  after  death  from  the  disease,  we  can  positively  deny  the  existence  of 
rabies. 

A  diagnosis  can  be  made  within  twenty-four  hours  by  rapid  fixation  and  mount- 
ing, and  is  easily  made  within  forty-eight  hours. 

The  diagnosis  by  the  method  of  Negri  has  advantages  over  the  above  in  that 
the  Negri  bodies  are  usually  found  early  in  the  disease,  are  not  affected  by  putre- 
factive changes  incident  to  delay  in  obtaining  the  material,  and  the  teehnic  is  more 
simple.  In  practice  a  small  portion  of  the  brain  should  be  taken  from  the  cortex 
of  the  cerebellum,  and  also  from  Amnion's  horn,  as  the  bodies  may  be  numerous 
in  one  area  and  not  in  the  other.  The  pieces  of  tissue  may  be  fixed  in  Zenker's 
fluid  embedded  in  paraffin,  and  stained  with  eosin  and  methylene  blue.  The  bodies 
show  red  against  the  blue  background  of  the  cell.  The  stains  of  Mann  and  Eoman- 
owsky  are  especially  recommended. 

The  process  of  hardening  and  cutting  may  be  dispensed  with  and  the  exami- 
nation for  Negri  bodies  made  directly  in  the  fresh  tissues  by  the  smear  method, 
which  has  been  found  very  satisfactory.  It  has  the  great  advantage  of  giving 
practically  an  immediate  diagnosis.  It  is  described  by  Gorham  as  follows:  The 
top  and  occipital  portions  of  the  skull  are  removed,  and,  without  taking  out  the 
brain,  pieces  3  to  4  mm.  in  diameter  are  taken  from  the  cerebral  cortex  in  the 
region  of  the  crucial  sulcus,  the  cortex  of  the  cerebellum,  and  the  hippocampus 
major.  These  are  placed  on  a  well-cleaned  slide  and  crushed  under  a  cover-glass 
until  the  matter  spreads  to  the  edge  of  the  cover,  which  is  then  drawn  slowly  and 
evenly  the  length  of  the  slide,  leaving  a  uniform  film  of  brain  matter.  The  slide 
is  then  immersed  in  wood  alcohol  for  one  to  three  minutes  and  dried  in  the  air. 
The  stain  is  made  by  adding  2  drops  of  a  saturated  alcoholic  solution  of  rose  anilin 
violet  and  16  drops  of  a  one-half  saturated  aqueous  solution  of  methylene  blue 
to  18  c.c.  of  distilled  water.  Elood  the  slide  with  this  stain  and  heat  gently  until 
steam  rises,  wash  in  water  and  dry.  The  Negri  bodies  appear  as  pink,  crimson, 
or  magenta  inclusions  in  the  blue  nerve  cells.  The  color  taken  depends  on  the 
condition  of  the  material  and  the  proper  mixture  of  the  stains.  In  early  cases 
the  bodies  are  found  only  in  the  large  cells,  while  in  advanced  cases  they  are  found 
in  all  kinds  of  nerve  cells. 

Yolpino's  osmic-acid  method  is  rapid  and  simple.  A  portion  of  the  horn  of  Am- 
nion is  removed  and  cut  into  segments  3  to  4  mm.  thick,  which  are  put  into  test- 
tubes  containing  4  to  5  c.c.  of  a  one-per-cent  solution  of  osmic  acid.  After  five  to  six 
hours  or  longer  they  are  removed  and  washed  in  water  for  half  an  hour,  then  put 
into  absolute  alcohol  for  three  to  four  hours.     They  may  then  be  cut  by  hand  and 


KAMI  131 

mounted  is  glycerin.  It  is  noi  necessary  to  harden  the  tissue,  since  a  fairly  thin 
section  can  be  readily  pressed  out  on  the  slide.  The  preparation  is  brownish  in 
color,  the  cells  are  lighl  coffee-color,  the  nuclei  paler,  and  the  nucleoli  Btrongly 
colored.  The  Negri  bodies  are  seen  in  the  cells,  and  resemble  nucleoli.  There 
may  be  one  or  several  to  a  cell. 

The  discovery  of  Negri  ha-  been  abundantly  confirmed,  and  while  the  etiological 
significance,  as  well  as  the  nature  of  the  bodies,  is  -till  in  doubt,  they  have  been 
shown  to  be  very  valuable  for  the  purpose  of  making  a  rapid  histological  diagnosis. 
Bertarelli  stales  thai  in  more  than  1,000  examinations  the  Negri  bodies  were  never 
found  in  animals  Free  from  rabies,  and,  on  the  other  hand,  wen'  present  in  all 
infected  animals,  with  three  exceptions.  Poor,  at  the  Health  Department  Labo- 
ratory, New  York,  has  examined  material  from  1^  cases  of  rabies  from  natural 
infection,  L6  cases  of  the  inoculation  disease,  and  22  controls.  The  Negri  bodies 
were  found  in  all  cases  of  natural  infection,  and  in  all  of  the  inoculation 
except  one  dog  which  was  killed  on  the  first  appearance  of  nervous  symptoms. 
Among  the  controls  one  case  of  experimental  tetanus  showed  a  few  minute  eosino- 
phil bodies  in  the  Purkinje  cells  of  the  cerebellum,  which,  however,  could  he 
differentiated  from  the  Negri  bodies.  He  confirms  fully  the  diagnostic  value  of 
the  method. 

Clinical  Diagnosis  of  Rabies  in  Dogs. — The  period  of  incubation  in  dogs  is 
said  to  be  shorter,  on  the  average,  than  in  man.  Seven  days  the  shortest  period. 
Thirty  days  as  an  average,  though  it  may  be  prolonged  to  eight  months.  The 
disease  is  ordinarily  described  as  occurring  in  two  types:  the  furious  and  the 
paralytic  type,  according  to  the  predominance  of  one  or  the  other  set  of  symp- 
toms. In  some  eases  the  stage  of  excitement  is  prolonged  for  several  days,  and 
is  followed  by  a  short  paralytic  stage  just  before  death,  while  in  others  the 
stage  of  excitement  is  very  short  while  the  paralytic  symptoms  are  marked 
from  the  outset.  The  latter  type  is  fairly  common  in  dogs,  and  notably  so 
after  experimental  inoculation.  It  is  said  to  be  the  prevalent  type  in  Turkey. 
It  is  far  less  dangerous  to  man  than  the  furious  type,  since  the  muscles  of  the 
jaws  are  paralyzed  so  that  the  animal  cannot  bite. 

Symptoms  of  the  Furious  Type. — The  early  symptoms  consist  of  chang  - 
in  disposition.  The  animal  is  restless,  uneasy,  and  excitable.  He  will  obey 
his  master,  hut  not  so  quickly  as  in  health.  The  appetite  remain-  good,  and 
may  he  excessive.  A  very  constanl  and  highly  suspicious  symptom,  which 
should  be  the  signal  for  confining  the  animal  and  keeping  him  under  close 
observation,  is  the  disposition  to  swallow  indigestible  articles — pieces  of  wood, 
straw,  dirt,  etc.  The  animal  gnaw-  and  tears  at  woodwork,  blankets,  rugs,  and 
other  similar  articles  in  an  unaccustomed  manner.  Alternate  periods  of  de- 
pression and  of  excitement  are  observed.  The  animal  seeks  solitude,  hide-  in 
dark  corners,  and  avoids  his  friends,  and  again  is  more  demonstrative  and 
affectionate  than  normal.  At  this  time  he  may  oxhil.it  signs  of  transient  de- 
lirium, watching  and  attacking  imaginary  objects.  The  animal  is  now  very 
dangerous,  and  may  even  bite  his  friends,  if  startled.  Presently  spasmodic 
contraction  of  the  muscles  of  deglutition  comes  on.     The  animal  i-  no  longer 


132  SPECIAL  DISEASES    OF   WOUNDS 

able  to  eat.  He  may  choke,  as  though  a  foreign  body  were  in  the  throat,  and 
the  examination  of  the  mouth  is,  of  course,  dangerous.  The  sound  of  the  bark 
is  altered,  and  ends  in  a  high-pitched  howl  different  from  the  ordinary  voice. 
The  successive  yelps  are  not  followed  by  complete  closure  of  the  jaws.  There 
is  no  fear  of  water,  and  the  animal  continues  to  drink  greedily  until  swallowing 
becomes  impossible.     It  is  noteworthy  that  there  is  never  fear  of  water  in  dogs. 

The  animal  soon  reaches  the  furious  stage.  He  has  hallucinations  of  sight 
and  hearing,  attacks  furiously  his  master  or  any  other  person  who  crosses  his 
path.  Unless  confined,  he  may  run  for  long  distances — many  miles — finally 
returning  home  or  continuing  until  he  drops  from  exhaustion.  His  coat  is 
rough  and  dirty,  his  tail  between  his  legs,  his  mouth  partly  open,  and  frothy, 
tenacious  saliva  drops  from  his  jaws.  He  usually  runs  straight  ahead,  and 
does  not  turn  out  of  his  way  to  bite  unless  interfered  with.  The  duration  of 
this  stage  may  be  only  a  few  hours  or  may  last  three  or  four  days.  It  is  fol- 
lowed by  the  paralytic  stage,  characterized  by  progressive  weakness  of  the 
muscles,  emaciation,  paralysis  of  the  muscles  of  swallowing  and  of  the  jaw. 
The  mouth  hangs  open,  and  cannot  be  closed.  The  animal  staggers  in  his  gait, 
and  is  finally  unable  to  stand.  There  is  gradually  increasing  dyspnea.  There 
may  be  general  convulsions.  Stupor  sets  in,  from  which  the  animal  can  be 
aroused  only  with  difficulty.  Death  occurs  from  exhaustion  and  complete  paral- 
ysis. The  duration  of  the  disease  is  from  three  to  six  days,  rarely  as  long 
as  ten.  The  furious  type  is  the  most  common  form,  and  occurs  in  about  eighty 
per  cent  of  the  cases. 

Paralytic  Type. — The  paralytic  type  of  the  disease  is  less  common,  and 
far  less  dangerous  to  man.  It  commences,  as  in  the  other  form,  by  restlessness 
and  excitement,  followed  by  the  desire  for  seclusion,  so  that  the  animal  hides 
and  avoids  observation.  The  stage  of  maniacal  fury  is  wanting.  The  typical 
symptoms  begin  with  paralysis  of  groups  of  muscles,  extending  to  other  groups 
until  all  the  muscles  are  paralyzed.  The  muscles  first  affected  are  those  of  the 
jaw.  The  mouth  hangs  open  and  cannot  be  closed,  swallowing  is  impossible, 
the  tongue  hangs  out,  and  becomes  dry  and  brown.  The  animal  is  quite  unable 
to  bite,  and  apparently  does  not  wish  to  do  so.  The  saliva  drools  from  the 
mouth  as  in  the  other  form.  The  duration  of  the  disease  is  very  short ;  death 
occurs  in  from  two  to  four  days,  as  a  rule,  of  complete  paralysis.  Forms  inter- 
mediate between  these  two  are  not  uncommon. 

The  Disease  in  Man. — Premonitory  Symptoms. — The  wounds  from  a  rabid 
bite  usually  heal  without  more  reaction  than  is  common  in  other  similar  wounds. 
In  some  cases  there  is  marked  depression  of  spirits  and  anxiety,  though  this 
may  have  no  relation  to  the  disease  itself ;  still,  it  has  been  observed  in  children 
and  in  adults  who  did  not  know  that  they  had  been  bitten  by  a  rabid  animal. 
Toward  the  end  of  the  period  of  incubation  there  may  be  pain  and  tingling. 
or  numbness  in  the  scars,  or  pain  along  the  course  of  the  principal  nerve  trunks 
of  the  affected  limb.  The  first  symptoms  of  the  disease  are  usually  marked 
mental  depression,  together  with  Iryperesthesia  of  the  skin  and  of  the  special 


RABIES  133 

senses.  There  are  sometimes  chilly  sensations,  or  n  chill  and  a  rise  of  tern 
perature  amounting  to  two  or  three  degrees.  After  a  few  hours  or  a  day  the 
patienl  has  a  sense  of  constriction  in  the  throat  Swallowing  becomes  difficult 
'I  lure  is  a  sense  of  oppression  in  the  chest.  The  voice  becomes  hoarse.  Mental 
irritability,  intense  anxiety,  and  suspicion  exist  Attacks  of  maniacal  delirium 
are  only  noted  in  the  later  stages  of  the  disease.  There  is  a  moderate  rise  of 
temperature — 1<><)  to  KM  b\— and  a  rapid  pulse.  In  some  cases  the  tem- 
perature will  rise  no  higher,  in  others  there  is  a  progressive  increase  in  the 
fever  until  death,  so  thai  the  temperature  maj  reach  KM  or  L05  F.,  or  even 
higher,  during  the  lasl  hours  of  the  disease.  The  pulse  regularly  becomes  more 
and  more  rapid   until  death.      It    is  at   first    full,  and   later  OB   becomes  more  and 

more  rapid,  feeble,  and  compressible. 

Stack  OF    EXCITEMENT. —  As   the  hours  go  by  the  condition   of  the   patient 

grows  rapidly  worse;  there  is  an  ever-increasing  anxiety,  amounting  to  extreme 

terror.  The  face  is  pale,  and  horror  is  depicted  on  every  lineament.  There  is 
extreme  thirst.  The  patienl  makes  desperate  efforts  to  drink  water,  tint  the 
attempts  to  swallow  cause  a  spasm  of  the  muscles  of  the  throat.  The  water  is 
ejected  from  the  mouth  with  some  force.  These  futile  efforts  lead  to  a  dread 
of  water,  until  the  mere  attempt  to  take  it,  or  even  the  sight  of  water  will 
produce  spasms  of  the  muscles  of  deglutition  and  respiration,  with  a  sense 
of  suffocation,  cessation  of  respiration,  and  intense  agony  of  mind.  These 
spasms  produced  by  slight  external  sources  of  irritation  are  the  most  con- 
slant  and  characteristic  feature  of  the  disease.  Owing  to  the  intense  hyper- 
esthesia of  the  skin  and  of  all  the  special  senses,  the  convulsive  attacks  may 
be  brought  <>n  by  a  bright  light,  by  a  sudden  noise,  by  a  draught  of  air,  or  by 
an  odor.  The  spasms,  at  first  confined  to  certain  groups  of  muscles,  become 
general.  They  are  tetanic  in  character.  There  may  be  opisthotonos,  with  sus- 
pension of  respiration.  In  some  cases  they  resemble  the  convulsions  of  hys- 
teria. During  the  convulsions  the  voice  is  changed  in  character,  and  may 
acquire  a  quality  which  has  been  likened  to  the  hark  of  a  dog.  Between  the 
convulsive  attacks  the  muscles  are  relaxed,  thus  differing  from  tetanus,  hut  as 
time  goes  on  the  seizures  are  more  frequent  and  more  prolonged.  The  patient 
through  terror  and  agony  becomes  delirious  during  the  attacks.  In  the  inter- 
vals he  can  usually  he  recalled  to  his  senses.  While  maniacal  he  may  do  him- 
self or  others  serious  injury,  and  may  strive  to  bite  those  about  him.  There 
is  marked  salivation  and,  since  the  patient  cannot  swallow,  the  viscid  saliva 
drools  from  the  mouth.  He  is  continually  spitting  in  his  efforts  to  get  rid  of  it. 
Vomiting  is  frequent.  The  vomited  matter  may  contain  blood.  During  the 
attacks  there  is  intense  dyspnea,  due  to  the  spasm  o(  the  diaphragm  and  inter- 
costal muscles,  though  the  glottis  is  not  closed.  Death  may  occur  during  one 
of  the  prolonged  spasms  from  asphyxia.  The  duration  o{  the  stage  of  excite- 
ment is  from  one  and  a  half  to  three  days. 

Paralytic  Stage. — A  short  time  before  death  the  convulsive  attacks  and 

the  delirium  subside.      The  patienl   sinks   into  a   state  of   profound   exhaustion, 


134  SPECIAL  DISEASES   OF  WOUNDS 

from  which  he  does  not  rally.  Consciousness  may  be  preserved  to  the  last,  or 
may  be  preceded  by  coma.  There  is  complete  paralysis.  The  duration  of  this 
stage  is  usually  only  a  few  hours. 

Paralytic  Type  of  Rabies  in  Man. — It  is  said  that  the  furious  type  of  rabies 
more  commonly  follows  bites  about  the  head  and  hands.  Following  extensive 
bites,  notably  those  involving  much  laceration  of  tissue  in  the  extremities,  a 
form  of  the  disease  occurs  in  which  the  excitement,  delirium,  and  muscular 
spasms  are  entirely  wanting.  The  disease  runs  the  course  of  an  acute  ascend- 
ing spinal  paralysis.  The  first  symptoms  may  be  paralysis  of  the  lower  ex- 
tremities. In  other  cases  this  may  be  preceded  by  pain  and  weakness  of  the 
bitten  limb.  Later  the  sphincters  and  the  muscles  of  the  trunk  are  paralyzed. 
Death  occurs  from  paralysis  of  the  muscles  of  respiration.  The  heart  may 
continue  to  beat,  if  artificial  respiration  is  performed,  for  many  hours  after 
natural  breathing  has  ceased.  In  these  cases  the  diagnosis  may  be  difficult, 
but  may  be  established  certainly  by  the  inoculation  of  animals. 

Differential  Diagnosis. — Kabies  may  be  confounded  with  hysteria,  tetanus, 
and  strychnin  poisoning.  With  hysteria  when  the  patient  has  informed  him- 
self of  the  characteristic  symptoms  of  hydrophobia,  or  when  they  are  suggested 
to  him  by  bystanders.  The  typical  spasms  of  deglutition  and  respiration  are 
not  easy  to  feign,  and  these  persons,  are  apt  to  carry  in  their  heads  some  of  the 
popular  fallacies  in  regard  to  the  true  disease.  I  recall  such  a  case  seen  some 
years  ago.  The  patient  was  a  man  who  was  brought  to  the  Roosevelt  Hospital 
in  an  ambulance,  said  to  be  suffering  from  hydrophobia.  He  seemed  at  first 
to  be  entirely  unconscious  of  his  surroundings.  He  wept  copiously — a  common 
symptom  of  hysteria.  He  had  frequent  repeated  general  convulsions,  with 
opisthotonos,  but  during  them  breathing  was  carried  on  in  a  normal  manner. 
His  face  was  flushed,  his  pulse  was  rapid  from  violent  exercise,  his  temperature 
was  normal.  He  continually  imitated  the  barking  and  growling  of  a  dog.  He 
seized  pillows  and  the  bedclothing  in  his  teeth,  and  by  pulling  and  shaking 
actually  tore  them  to  tatters.  When  suggestions  were  made  by  the  bystanders 
as  to  true  and  fanciful  symptoms  of  hydrophobia,  he  imitated  each  in  turn. 
He  growled  and  spat  freely  about,  but  did  not  attempt  to  injure  the  bystanders. 
He  was  put  partly  under  the  influence  of  chloroform,  on  emerging  from  which 
his  symptoms  disappeared. 

Tetanus. — The  incubation  period  of  tetanus  is  usually  much  shorter  than 
that  of  hydrophobia.  (See  Tetanus.)  The  muscular  contractions  begin  nearly 
always  in  the  masseter  muscles.  There  is  no  lockjaw  in  hydrophobia.  While 
convulsive  seizures  occur  in  tetanus,  the  muscles  are  not  relaxed,  but  remain 
hard  and  rigid  between  the  attacks.  In  tetanus,  Risus  sardonicus  is  present; 
absent  in  hydrophobia.  Maniacal  excitement  does  not  occur  in  tetanus.  Swal- 
lowing is  usually  possible  during  the  early  part  of  the  disease. 

Strychnin  Poisoning. — The  symptoms  come  on  immediately  after  the  in- 
gestion of  the  poison.  There  are  violent  generalized  spasms  of  all  the  muscles 
of  the  body,  sometimes  with  cessation  of  respiration  and  cyanosis.     There  is 


ANTHRAX  L35 

Ki-n-  sardonicus,  absent  in  hydrophobia.  There  is  complete  muscular  relax- 
ation between  the  convulsions.  In  marked  cases  opisthotonos  occurs  with  every 
convulsion.  There  is  marked  photophobia,  ;m<  1  objects  appear  green.  The 
intellect  is  clear  throughout.  The  convulsions  in  strychnin  poisoning  continue 
only  a  few  hours,  or  at  mosl  a  day,  ending  in  death  or  complete  recovery. 

ANTHRAX 

Synonyms.  —  Malignant  pustule;  French,  Charbon;  German,  Milzbrand; 
Wool-sorter's  I  disease. 

Definition. — Anthrax  is  an  acute  infectious  disease  caused  by  inoculation 
with    the   anthrax   bacillus — a    rod-shaped    bacterium   forming   spores   outside 

the  animal   body. 

Surgical  Rutkkiology.1 — The  bacilli  occur  in  the  blood  and  tissues  of  man 
or  animals  attacked  by  anthrax.  They  are  from  (i  to  8  //.  long  and  about  1.".'  ft 
broad,  with  square  or  Blightly  concave  ends.  They  sometimes  occur  in  long  chains. 
frequently  in  pairs  arranged  end  to  end.  They  stain  well  with  all  the  basic  anilin 
colors,  and  by  Gram's  method,  although  a  cautious  application  of  the  decolorizing 
fluid  is  necessary  in  order  to  avoid  removing  the  gentian  violet  from  many  of  the 
bacilli.  On  gelatin  plates  the  colonies  develop,  in  from  twenty-four  to  thirty-six 
hours,  as  very  wavy  bodies,  radiating  from  the  center  outward  like  locks  of  hair. 
In  a  day  or  two  a  liquefaction  begins  which  slowly  extends  through  to  the  bottom 
of  thi'  gelatin.  In  gelatin  tidies  an  appearance  is  seen  similar  to  that  of  the  col- 
onies in  gelatin  plates,  the  growth  appearing  along  the  needle  track  as  a  whitish 
line  sending  out  radiating  lines  and  presenting  the  appearance  of  an  inverted  fir 
tree,  whitish,  and  accompanied  by  liquefaction  slowly  progressing  downward  from 
the  upper  portion  of  the  gelatin.  In  agar  plates  the  colonies  are  apparent  twelve 
hours  after  incubation  at  a  temperature  of  37°  C.  under  a  low  power,  presenting 
this  very  marked  wavy  appearance.  Under  a  high  power  the  wavy  appearance 
apparently  radiates  out.  and  terminates  not  in  a  point,  hut  in  a  turn  upon  itself; 
so  that  it  is  probable  that  the  entire  colony  is  a  thread  twisted  on  itself.  On  the 
surface  of  agar  there  is  a  moist,  profuse  growth,  slightly  elevated,  and  whitish  in 
color,  -hewing  the  wreathed  appearance  that  is  seen  in  plate  cultures.  The  colonies 
on  blood  serum  are  the  same  as  on  agar.  In  bouillon  there  appears  a  shreddy 
growth  that  later  becomes  more  abundant,  settling  as  a  flocculent  mass  to  the  bottom 
of  the  fluid.  On  potato  there  is  a  thick,  moist,  whitish  layer,  without  any  special 
characteristics.  The  bacillus  grows  rapidly,  producing  spores,  does  not  produce 
gas,  liquefies  gelatin  slowly,  does  not  produce  pigment,  is  stained  readily  with  any 
of  the  anilin  colors,  and  usually  by  Gram's  method,  and  is  pathogenic  to  all  sus- 
ceptible  animals. 

For  diagnostic  purposes  cover-glass  preparations  may  he  made  from  the  fluid 
in  the  vesicles,  or  from  scrapings  of  the  incised  pustule,  and  may  he  stained  with 
watery  solutions  of  any  of  the  anilin  colors,  and  by  Gram's  method.  The  bacilli  are 
not  usually   found   in   the  blood.     Muir  and    Ritchie  give  a   very  wise  caution   that 


■Quoted  from  II.  C.  Ernst,  "International  Text-Book  of   Surgery,"  vol.  i,  p.  37.  Warren 
Gould. 


136  SPECIAL   DISEASES    OF   WOUNDS 

the  parts  should  be  handled  carefully  and  gently  in  attempts  at  diagnosis,  other- 
wise the  diffusion  of  the  bacilli  into  surrounding  tissues  may  be  forced,  and  the 
condition  greatly  aggravated.  Plate  cultures  should  also  be  made,  as  well  as  inocu- 
lations, if  positive  results  are  not  obtained  by  the  microscope  alone. 

Occurrence — Anthrax  occurs  most  often  among  the  mammalia,  including 
man,  notably  among  the  domesticated  herbivora — cattle  and  sheep,  less  often 
horses.  Animals  dying  of  the  disease  and  buried  in  a  pasture  become  wide- 
spread sources  of  infection.  The  bacilli  in  the  carcass  form  resistant  spores, 
and  may  be  disseminated  over  a  large  area  by  water,  by  wind,  or  mechanically. 
Thus  an  entire  pasture  or  small  watercourse  may  become  infected,  and  epidem- 
ics of  anthrax  among  stock  often  arise  in  this  way. 

Sources  of  Infection. — In  animals,  as  in  man,  the  disease  may  be  acquired 
in  three  ways:  (1)  By  local  inoculation;  (2)  by  entrance  into  the  respira- 
tory passages;  (3)  by  ingestion,  with  food  into  the  alimentary  canal.  In  man 
the  disease  is  commonly  contracted  from  handling  the  hides  and  hair  or  bodies 
of  animals  infected  with  anthrax  (wool-sorter's  disease),  so,  also,  by  farmers, 
butchers,  veterinary  surgeons,  and  occasionally  by  pathologists  or  surgeons 
during  experimental  work  in  laboratories  or  during  autopsies.  Flies  are 
believed  also  to  transmit  the  disease.  Infection  through  the  use  of  imperfectly 
sterilized  catgut  has  been  reported  (sheep's  intestine).  The  pustular  form  of 
the  disease  by  inoculation  of  a  wound  or  abrasion  of  the  cutaneous  surface  is 
much  more  common  in  man  than  is  inoculation  by  inhalation  or  by  the  inges- 
tion of  infected  food,  although  inoculation  by  inhalation  does  sometimes  occur 
among  those  who  sort  wool.  Recent  wounds  and  abrasions  of  the  integument 
not  covered  by  granulations  are  the  ports  of  entry.  The  exposed  portions  of 
the  body  are  the  usual  seats — the  face  and  neck,  the  hands  and  arms;  lastly, 
the  low7er  extremities. 

Period  of  Incubation. — The  period  of  incubation  is  two  or  three  days,  some- 
times six,  and  usually  without  noticeable  prodromal  symptoms.  The  pustule 
develops  first  as  a  vesicle  containing  pinkish,  later  bluish,  fluid,  upon  a  slightly 
swollen,  reddened  or  purplish  base.  The  vesicle  soon  bursts  and  forms  a  crust 
of  a  black  color,  due  partly  to  dried  blood  and  partly  to  necrosis  of  the  super- 
ficial tissues.  The  original  pustule  begins  of  the  size  of  a  pea,  or  sometimes 
it  is  as  large  as  a  ten-cent  silver  piece.  The  swollen  edges  of  the  pustule  rise 
above  the  level  of  the  skin,  and  the  central  crust  appears  depressed.  The 
swelling  and  redness  spread,  and  an  areola  of  secondary  vesicles  is  formed 
upon  the  inflamed  skin.  The  subjective  sensations  of  burning,  itching,  and 
tenderness  are  present.  There  is  at  this  time  moderate  constitutional  depres- 
sion and  a  moderate  rise  of  temperature.  There  is  rapid  swelling,  edema,  and 
induration  of  the  surrounding  skin  and  swelling  of  the  communicating 
lymphatic  glands.  If  the  central  scab  be  removed  at  this  time  a  necrotic  ulcer 
is  exposed,  discharging  a  thin,  blood-stained  fluid  containing  usually  numer- 
ous anthrax  bacilli,  which  can  be  recognized,  by  staining,  under  the  microscope. 


ACTINOMYCOSIS  137 

Variations  in  the  Course  of  the  Disease. —  The  subsequent  progress  of  the 
disease  varies  a  good  deal  in  different  cases.  In  some  the  pustule  may  have 
existed  for  several  days  without  the  anthrax  bacilli  leaving  the  immediate 
vicinity  of  the  pustule,  where  they  may  be  found,  for  the  most  pari  in  the  more 
superficial  layers  of  the  true  skin.  In  one  of  my  own  cases  excision  of  1 1 1* - 
pustule  was  made  on  the  fifth  day,  and  the  bacilli  were  closely  grouped  around 
the  original  pustule  and  absent  from  the  outer  portions  of  the  section.  In 
other  cases  a  very  rapid  dissemination  takes  place  without  much  redness  of 
the  skin,  hut  with  rapidly  progressive  brawny  edema  and  profound  constitu- 
tional poisoning,  ending  in  three  to  five  days  alter  the  beginning  of  the  disease 
in  death,  preceded  by  prostration,  high  fever,  delirium,  diarrhea,  and  collapse. 

Infection  through  the  lungs  runs  the  course  of  an  intense,  septic,  and  rap- 
idly fatal  pneumonia.  Intestinal  infection  is  characterized  by  Bymptoms  of 
Midden  and  violent  inflammation  of  the  alimentary  canal  with  vomiting,  diar- 
rhea, and  speedy  death  in  collapse. 

Diagnosis. — The  diagnosis  is  established  in  ordinary  cases  by  the  charac- 
teristic appearance  of  the  pustule  and   by   r< gnition  of  the  anthrax   bacilli 

in  the  discharge,  or  in  scrapings  from  the  pustule,  or  in  sections  of  the  tissue 
under  the  microscope  after  the  pustule  has  been  excised,  or  by  inoculations  of 
animals. 

It  is  a  mistake  to  suppose  that  in  man  the  diagnosis  of  anthrax  can  be  made 
from  examining  the  blood   from  the  general  circulation  for  anthrax  bacilli.     Only 

in  exceptional  eases  of  anthrax  of  a  septicemic  type  and  at  a  late  stage  can  the 
bacilli  be  developed  from  blood  cultures.  In  most  instances  cultures  made  from 
the  blood  remain  sterile.     (Ewing.) 

It  is  well  to  remember,  however,  that  not  every  pustule  having  a  black 
scah  at  its  center  is  anthrax.  I  have  excised  several  which  have  been  found 
to  be  due  entirely  to  Staphylococcus  pyogenes  aureus.  They  lacked,  however, 
the  secondary  vesication  upon  the  skin  surrounding  the  pustule.  The  diag- 
nosis of  those  cases  dying  of  pulmonary  anthrax  and  of  intestinal  anthrax 
might  be  made  before  death  by  the  recognition  of  the  bacilli  in  the  sputum  or 
in  the  discharges  from  the  bowel  respectively,  and  in  some  instances  by  a 
history  of  exposure  to  the  disease  a  probable  diagnosis  mighl  be  arrived  at. 
A  recognition  postmortem  in  hardened  sections  of  the  liver,  the  lungs,  and 
the  spleen  would  reveal  abundant  characteristic  bacilli  embedded  in  the  endo- 
thelial lining  of  the  blood  capillaries  of  these  organs  especially. 

ACTINOMYCOSIS 

Actinomycosis  is  a  chronic  infectious  disease  occurring  in  cattle  and  in 
man.  It  is  caused  by  the  growth  in  the  tissues  of  the  so-called  ray  fungus, 
an  organism  occurring  in  certain  grains — notably  in  barley  and  in  rye.  The 
disease    has    in    nianv    instances    been    traced    directly    to    inoculation    with    the 


138  SPECIAL   DISEASES    OF   WOUNDS 

infected  grain  through  some  minute  traumatism,  and  a  spear  or  kernel  of  such 
grain  has  in  certain  cases  been  found  embedded  in  or  adherent  to  the  diseased 
tissues.  The  disease  in  cattle  is  known  as  "  lumpy  jaw,"  on  account  of  its 
localization  and  of  the  peculiar  hard  nodular  tumors  formed  upon  and  in  the 
neighborhood  of  the  lower  jaw  of  the  infected  animal.  In  the  tissues  of  these 
nodules  the  fungus  can  be  demonstrated  invariably.  In  man  the  disease  occurs 
somewhat  rarely,  and  yet  almost  every  surgeon  of  considerable  experience  has 
seen  one  or  more  cases.  Infection  from  diseased  animals  has  occurred,  but 
is  uncommon.  The  ingestion  of  infected  meat  has  been  thought  in  certain 
instances  to  account  for  the  production  of  the  disease ;  but  probably  in  the 
majority  of  cases  the  disease  is  introduced,  as  has  been  many  times  demon- 
strated, through  the  medium  of  infected  grain — barley,  rye,  wheat,  or  other 
cereal. 

Avenues  of  Infection. — Three  principal  ports  of  entry  are  recognized — 
the  mouth  and  throat,  the  respiratory  tract,  and  the  alimentary  canal,  occa- 
sionally through  wounds  of  the  external  integument.  When  in  the  mouth 
and  throat  the  fungus  gains  entrance  through  a  carious  tooth  or  through  one 
of  the  crypts  of  the  tonsil.  Sometimes  the  inoculation  takes  place  in  the 
tongue  or  through  some  portion  of  the  mucous  membrane  of  the  buccal  cavity ; 
probably  more  often  in  the  gums,  or  between  the  teeth  and  the  gums,  than 
elsewhere.  Undoubtedly  the  mouth  is  much  the  most  frequent  port  of  entry. 
In  the  lungs  the  infection  takes  place  through  aspiration  of  the  fungus  and 
inoculation  through  the  lining  membrane  of  the  air  passages.  In  the  abdom- 
inal type,  through  the  mucous  membrane  of  the  intestine.  The  cecum  and 
appendix  appear  to  be  the  regions  most  commonly  attacked,  but  other  portions 
of  the  gastro-intestinal  canal  may  also  be  infected.  Once  inoculated,  the  dis- 
ease tends  to  spread  slowly  by  continuity  of  structure,  but  dissemination  by 
the  blood  current  is  apparently  possible,  since  pyemic  forms  of  the  infection 
have  been  observed  with  the  formation  of  foci  in  widely  separated  organs. 

Essential  Lesion. — The  disease  is  characterized  by  production  of  nodular 
masses  of  inflammatory  tissue  exhibiting  in  their  structure  a  variety  of  lesions 
according  to  the  relative  age  of  the  infection  in  different  portions  of  infiltrated 
area.  The  older  portions  consist  of  dense  hard  masses  of  sclerosed  fibrous 
connective  tissue.  In  parts  less  ancient,  the  newly  formed  connective  tissue 
is  softer  and  is  infiltrated  with  leucocytes.  In  the  recent  portions  the  masses 
of  growing  fungus  are  surrounded  by  granulation  tissue,  containing  also  giant 
cells.  This  granulation  tissue  tends  to  undergo  purulent  softening  with  per- 
foration of  the  skin,  and  the  formation  of  sinuses  from  which  escape  a  thin 
purulent  discharge  containing  minute  granules  of  a  gray,  yellowish,  or  sulphur 
color,  of  such  a  size  as  to  be  visible  to  the  naked  eye. 

The  occurrence  of  these  granules  in  the  discharge  constitutes  the  char- 
acteristic and  diagnostic  feature  of  the  disease.  The  granules  are  often  of  the 
size  of  the  head  of  a  very  small  pin,  or  smaller ;  they  are  not  always  yellow 
in  color;  they  may  be  colorless,  like  jelly,  or  dark,  almost  black,  or  greenish, 


ACTINOMYl  OSIS  139 

or  white.  When  placed  under  the  microscope  these  granules  have  a  very 
characteristic  appearance;  they  may  be  examined  as  they  are,  or  stained  with 
picric  acid,  or  with  any  anilin  stain-  i.e.,  gentian  violet  or  hematoxylin 
They  do  ool  stain  by  Gram's  method,  excepl  in  the  tissues  of  the  ox.  The 
masses  are  seen  to  consisl  under  the  microscope  of  a  Bomewhal  rounded  body, 
toward  the  circumference  of  which  are  Been  arranged  in  a  radiating  manner 
translucent  filaments,  frequently  with  enlarged  or  clubbed  ends.  These  fila- 
ments may  sometimes  be  Been  to  branch  dichotomously.  Sometimes  -mall. 
rounded  bodies  may  be  Been  scattered  among  the  filaments;  these  are  the  spores 
or  conidia  of  the  fungus.  The  center  of  the  mass  is  composed  of  an  interlac- 
ing network  of  filaments.  The  diameter  of  the  filaments  is  aboul  5  /*.  A 
similar  demonstration  of  the  organism  can  usually  be  made  in  hardened 
tions  of  the  affected  tissues,  surrounded  by  granulation  tissue  and  giant  cells 
or  pus.  By  double  staining  of  such  sections  with  picric  acid  and  fuchsin, 
the  fungus  then  appears  a  brillianl  yellow  and  the  surrounding  tissue 
cells  red. 

Clinical  Diagnosis. — The  recognition  of  actinomycosis  clinically,  as  it  occurs 
upon  the  pace  and  neck,  is  usually  not  very  difficult  If  the  superficial  Bofl 
parts  are  involved  there  will  be  found  a  chronically  inflamed  and  nodular 
area  upon  the  skin,  sometimes  over  the  body  of  the  lower  jaw,  sometimes  upon 
the  neck;  but  little  pain  will  usually  be  complained  of,  and  the  affection  will 
have  a  markedly  chronic  history.  The  progress  of  the  disease  is,  however, 
insidious  and  widespread;  invasion  by  continuity  of  structure  is  not  uncom- 
mon; thus,  in  actinomycosis  of  the  upper  jaw,  the  antrum,  the  base  of  the 
skull,  and  the  temporo-maxillary  fossa  are  invaded;  in  actinomycosis  of  the 
lower  jaw,  the  soft  parts  of  the  neck,  and  even  the  mediastinum.  There  may  be 
simply  one  or  more  indurated  nodules  or,  more  commonly,  there  will  be  found 
several  nodules  or  parallel  ridges  elevated  above  the  skin,  some  of  which  arc 
broken  down  in  their  centers,  the  skin  thinned,  and  fluctuating,  suggesting 
somewhat  the  condition  of  an  inflamed  sebaceous  cyst,  or  a  subacute  periosteal 
abscess,  or,  if  the  skin  is  already  perforated,  sinuses  will  be  present  from  which 
may  be  extruded  a  thin  watery  pus,  usually  containing  the  characteristic  actino- 
mycotic grannies;  or  an  incision  of  one  of  the  fluctuating  areas  will  give  escape 
to  similar  material. 

If  the  disease  involves,  as  it  sometimes  does,  the  central  tissues  of  the 
jaw,  dilatation  and  enlargement  of  the  jaw  will  Ik-  produced,  later  with 
perforation  and  the  formation  of  sinuses.  In  such  cases  the  infiltration  of 
the  tissues  of  the  cheek  will  lead  to  more  or  less  complete  immobility  of  the 
jaw.  In  man  this  form  of  infection  is  less  common  and  less  characteristic  than 
in  animals.  The  cases  have  been  mistaken  for  central  sarcoma.  Confusion 
may  also  arise  when  an  epithelioma  of  the  jaw  becomes  infected,  breaks  down 
and  discharges  pus  containing  white  granules.     In  this  instance  the  granules 

are  epithelial  pearls.     In  these  cases  the  age  of  the  patient,  the  present t  a 

primary  growth  on  the  skin  or  mucous  membrane,  or  of  a  characteristic  ulcer 


140  SPECIAL  DISEASES    OF  WOUNDS 

in  the  mouth,  and  the  rapid  progress  of  the  disease,  will  render  the  diagnosis 
clear,  and  yet  I  have  seen  good  surgeons  err  in  similar  cases. 

Upon  the.  tongue  the  disease  occurs  as  one  or  more  indurated  nodules 
usually  not  larger  than  a  pea,  which  may  break  down,  leaving  a  small  cavity 
lined  with  yellowish  necrotic  tissue,  or  with  somewhat  indurated  granulation 
tissue.  In  one  case  which  I  saw,  in  the  clinic  of  Albert,  in  Vienna  in  1887, 
the  disease  existed  in  the  form  of  multiple  nodules  upon  the  dorsum  of  the 
tongue,  scattered  over  nearly  the  anterior  half  of  the  organ;  from  the  discharge 
and  from  scrapings  from  the  nodules  the  fungus  had  been  demonstrated. 

Actinomycosis  of  the  Lung. — Actinomycosis  of  the  lung  is  the  gravest 
form  of  the  disease ;  it  presents  the  signs  and  runs  the  course  in  many  instances 
of  ordinary  chronic  pulmonary  phthisis  of  a  severe  type,  and  is  usually 
complicated  by  septic  symptoms  due  to  mixed  infection  with  pyogenic 
microbes. 

Moderate  leucocytosis  has  been  observed  in  actinomycosis  of  the  lung  run- 
ning an  acute  course — 21,500  (Ewing).  There  is  loss  of  flesh  and  strength, 
night  sweats,  sometimes  hemoptysis.  The  pleura  and  the  diaphragm  are  fre- 
quently involved,  and  the  disease  may  perforate  the  thoracic  wall,  and  appear 
as  an  indurated  area,  or  an  abscess  upon  the  thorax,  usually  low  down ;  or 
the  diaphragm  may  be  perforated,  and  the  peritoneum  infected,  with  a  rapidly 
fatal  result.  The  diagnosis  in  these  cases  must  rest  upon  the  recognition  of 
the  fungus,  either  in  the  sputum  or  in  fluid  aspirated  from  the  pleura,  through 
a  large  needle.  The  continuous  absence  of  tubercle  bacilli  in  the  sputum, 
the  signs  and  symptoms  of  acute  pleuritis  with  marked  fever  of  a  septic  type, 
and  the  negative  results  of  aspiration,  or  the  withdrawal  of  merely  serous 
fluid  from  the  pleural  cavity,  together  with  a  boardlike  induration  of  the  soft 
parts  of  the  thorax,  and  repeated  careful  examination  of  the  sputum,  are  the 
means  of  diagnosis.  If  metastatic  foci  occur  in  distant  regions  their  con- 
tents may  clear  up  the  diagnosis. 

In  abdominal  actinomycosis  there  are  produced  the  symptoms  of  very 
varied  disturbance  of  the  alimentary  tract.  Pain,  of  a  colicky  character,  some- 
times diarrhea.  The  pains  are  sometimes  localized  and  sometimes  general. 
There  are  a  variety  of  other  irritative  symptoms  in  special  cases,  depending 
upon  the  organs  involved.  An  abdominal  tumor  or  induration  can  usually 
be  distinguished;  this  may  simulate  carcinoma  of  the  cecum  (the  usual  site) 
or  other  portion  of  the  gut,  or  intestinal  tuberculosis.  In  a  certain  number 
of  cases  involvement  and  perforation  of  the  abdominal  wall  may  take  place 
with  the  formation  of  a  dense  infiltration  of  the  tissues,  sometimes  with  the 
escape  from  the  sinuses  formed  of  the  characteristic  fungus.  The  granules 
may  also  be  discharged  through  the  rectum  or  through  the  bladder.  Other 
and  varied  localities  in  the  body  may  be  affected  by  this  disease.  The  diagno- 
sis will  depend,  as  in  other  instances,  upon  the  slow  and  often  rather  painless 
progress  of  the  condition,  by  the  formation  of  characteristic  areas  of  indurated 
tissue,  disseminated  spots  of  softening,  the  formation  of  sinuses,  and  the  rec- 


ACTINOMYCOSIS  111 

ognition  of  the  fungus  in  the  discharge  or  in  the  infected  tissues.  (See  Abdo- 
men.) 

Differential  Diagnosis. — Actinomycosis  of  the  tongue  i-  to  be  distinguished 
from  carcinoma  of  thai  organ  by  the  situation.  Cancer  more  commonly  begins 
on  the  side  of  the  tongue,  actinomycosis  near  the  tip.  Cancer  of  the  tongue 
is  exceedingly  painful,  actinomycosis  is  not  Progressive  ulceration  and  early 
involvement  of  the  lymphatics  of  the  submaxillary  triangle  are  typical  of 
carcinoma;  they  are  abseni  in  actinomycosis,  <>r  al  leasl  not  marked.  Gum- 
mata  of  the  tongue  are  usually  Larger  than  the  nodules  formed  by  actinomy- 
cosis, they  begin  in  the  submucous  tissue,  and  when  broken  down  tin-  crater- 
like  appearance  of  the  excavation  lined  by  characteristic  gummatous  tissue 
should,  when  taken  in  connection  with  the  history  and  the  possible  presence 
of  other  evidence  of  the  disease,  serve  to  distinguish  them  from  actinomycosis. 
The  administration  of  iodide  of  potash  would  no1  serve  as  a  means  of  differ- 
entiation between  these  two  conditions,  because  either  process  might  be  cured 
thereby.  Tuberculous  ulcers  of  the  tongue  occur  usually  in  the  presence  of 
tuberculosis  of  the  lungs;  they  are  soft  ulcerations,  frequently  with  a  caseous 
basis,  or  covered  with  flabby  granulations.  They  are  exceedingly  tender  and 
painful.  rldie  recognition  of  tubercle  bacilli  in  the  scrapings  of  the  ulcer  is 
usually  not   difficult. 

Identification  of  Actinomycosis  by  Cultures. — The  following  is  quoted  from 
The  Journal  of  Medical  Research,  vol.  xiii,  Xo.  4,  May,  1905,  "The  Biology 
of  the  Micro-organism  of  Actinomycosis,"  by  .lames  Homer  Wright,  M.D.: 

As  the  result  of  my  experience  I  would  recommend  the  following  procedure 
for  the  isolation  of  the  micro-organism  of  actinomycosis.  The  granules,  preferably 
obtained  from  closed  lesions,  are  firsl  thoroughly  washed  in  sterile  water  or 
bouillon  and  then  crushed  and  disintegrated  between  two  sterile  glass  slides.  If 
one  is  working  with  a  bovine  case,  it  is  well  to  examine  microscopically  the  dis- 
integrated material  after  mixing  it  with  a  drop  or  two  of  bouillon  under  a  cover- 
glass  to  see  if  filamentous  masses  are  present.  If  they  were  not,  or  if  they  are 
very  few,  proceed  no  further,  but  begin  again  with  another  granule,  because  the 
granules  in  bovine  lesions  sometimes  contain  no  living  filaments  at  all.  but  may 
he  composed  entirely  of  degenerate  structures  from  which  no  growth  of  the  micro- 
organism can  be  expected.  If  filaments  and  filamentous  masses  are  thus  found  to 
be  present  in  the  granule,  then  the  disintegrated  products  of  the  granule  are  to 
be  transferred  by  means  of  the  platinum  loop  to  melted  one-per-cent  dextrose 
agar  contained  in  test-tubes  tilled  to  the  depth  of  about  7  or  S  cm.  which  have 
been  cooled  to  about  40°  C.  The  material  is  thoroughly  distributed  throughout 
the  melted  agar  by  means  of  the  loop,  and  the  tube  then  placed  in  the  incubator. 
Severed  tubes  should  thus  be  prepared.  At  the  same  time  a  number  of  granules, 
after  thorough  washing  in  sterile  water  or  bouillon,  should  be  placed  on  the  sides 
of  sterile  test-tubes  plugged  with  cotton  and  kept  at  room  temperature  in  the  dark. 

The  sugar  agar  tubes  inoculated  as  above  described  should  be  examined  from 
day  to  day  for  the  presence  of  the  characteristic  colonies  in  the  depths  o\'  the 
agar.      If   very  many  colonies   of   contaminating   bacteria    have   developed   in   the 


142  SPECIAL   DISEASES    OF   WOUNDS 

tubes,  it  will  probably  be  very  difficult  or  impossible  to  isolate  the  specific  micro- 
organism. If  there  are  few  or  no  contaminating  colonies,  then  the  colonies  of 
the  specific  micro-organism  should  be  expected  to  develop  in  the  course  of  two 
or  three  days  to  a  week.  If  a  good  number  of  living  filaments  of  the  micro-organ- 
ism have  been  distributed  throughout  the  agar,  the  specific  colonies  that  develop 
will  be  very  numerous  in  the  depths  of  the  agar,  especially  throughout  a  shallow 
zone  situated  about  5  to  12  mm.  below  the  surface  of  the  agar-agar. 

When  the  presence  of  the  characteristic  colonies  has  been  determined,  slices  or 
pieces  of  the  agar  containing  colonies  are  to  be  cut  out  of  the  tube  by  means  of 
a  stiff  platinum  wire  with  a  flattened  and  bent  extremity.  A  piece  of  the  agar 
is  to  be  placed  on  a  clean  slide  and  covered  with  a  clean  cover-glass.  It  is  to  be 
examined  under  a  low  power  of  the  microscope,  and  an  isolated  colony  selected 
for  transplantation.  By  obvious  manipulations,  under  continuous  control  of  micro- 
scopic observation,  the  selected  colony  together  with  a  small  amount  of  the  sur- 
rounding agar-agar  is  to  be  cut  out,  care  being  taken  to  be  sure  that  no  other  colony 
is  present  in  the  small  piece  of  agar-agar  containing  the  colony.  The  small 
piece  of  agar  thus  cut  out  should  not  have  a  greater  dimension  of  more  than 
2  mm.  The  piece  of  agar  is  then  transferred  from  the  slide  by  means  of  a  platinum 
loop  to  a  tube  of  sterile  bouillon,  where  it  is  thoroughly  shaken  up  in  order  to 
free  it  from  any  adherent  bacteria.  If  there  be  reason  to  believe  that  the  small 
piece  of  agar  has  been  very  much  contaminated  with  bacteria  it  should  be  washed 
in  a  second  tube  of  bouillon;  then  the  piece  of  agar  is  to  be  transferred  by  means 
of  the  platinum  loop  to  a  tube  of  melted  sugar  agar  cooled  to  40°  C.  It  should 
be  immersed  deeply  in  the  agar  and  the  tube  placed  in  the  incubator.  If  the 
colony  thus  transferred  to  the  agar-agar  is  capable  of  growth,  in  the  course  of 
some  days  it  will  have  formed  a  good-sized  colony  from  which  transplants  in 
various  culture  media  may  be  made. 

In  the  manner  described  several  small  pieces  of  agar  containing  single  isolated 
colonies  should  be  placed  in  sugar  agar  tubes,  because  the  chances  are,  as  already 
stated,  that  some  of  the  colonies  will  not  grow,  and  contaminations  with  other 
bacteria  may  occur. 

If  the  number  of  contaminating  colonies  is  so  great  in  the  original  agar  cul- 
tures from  the  granules  that  it  is  found  impossible  or  very  difficult  to  obtain 
specific  colonies  free  from  other  micro-organisms,  then  it  is  probably  not  worth 
while  to  expend  much  labor  with  the  task  of  isolation  from  these  original  agar 
tubes,  but  it  is  much  better  to  wait  until  the  granules  placed  on  the  sides  of  sterile 
test-tubes  have  dried  thereon  for  two  or  three  weeks  and  then  proceed  with  these 
granules  as  just  described  for  the  fresh  granules.  The  drying  of  the  granules  for 
this  length  of  time  will  probably  suffice  to  kill  off  most  of  the  contaminating  bac- 
teria and  enable  isolated  colonies  of  the  specific  micro-organism  to  be  obtained  in 
the  agar  suspension  cultures. 


MADURA   FOOT 

Synonyms. — Mycetoma ;  Fungus  foot  of  India. 

Closely  allied  to,  if  not  identical  with,   actinomycosis  is  a  disease  occur- 
ring endemically  in  certain  parts  of  India,  notably  in  the  neighborhood  of 


ERYSIPELOID  1  }.; 

the  city  of  Madura  in  southern    [ndia,  although  nol  confined  to  this  region, 
since  cases  occur  in  other  countries,  and   have  been  described   in    Italy  and 
both     North    and    South    America.      The    disease    is    essentially    a    chronic 
suppurative  process  beginning  beneath  the  integumenl  of  the  Bole  <»r  dorsum 
of  the  foot,  and  later  involving  the  deepei  part-,  muscles,  tendons,  and  1 
Sinuses  are  formed  which  discharge  pus  and  the  characteristic  rounded  m 
of  fungi,  cither  white  or  black  in  color.     The  sinuses  result  from  the  breaking 
down  of  hard  nodules,  precisely  as  is  the  case  in  actinomycosis.     The  dis 
is  very  chronic  and  gradually  involve-,  all  the  tissues  of  the  foot     I  I 
disuse,  the  muscles  of  the  leg  undergo  atrophy  and  the  limb  becomes  a  as 
appendage.     The  disease  is  usually  not  painful     The  diagnosis  is  made 

from  the  swelling,  the  hard  nodules,  the  sinuses,  and  the  recognition  of  the 
characteristic  nodules,  which  under  the  microscope  are  hardly  to  be  differen- 
tiated from  actinomycosis. 

ERYSIPELOID 

Synonyms. — Erythema  Migrans;  Rosenbach's  Erysipeloid. 

An  acute  inflammatory  affection  of  the  skin  of  the  fingers  and  hand,  char- 
acterized by  the  formation  of  sharply  defined  red  or  bluish-red  swollen  areas 
upon  the  skin,  attended  by  the  subjective  sensations  of  burning  and  itching. 
Constitutional  symptoms  are  wanting.  The  disease  is  caused  by  inoculation  of 
minute  wounds  or  abrasions  of  the  fingers  or  hand  with  bacteria.  Whether 
the  disease  is  produced  by  a  specific  germ  or  may  be  caused  by  several  kinds 
of  bacteria  i>  not  entirely  clear.  As  originally  investigated  and  described 
by  Rosenbach,  the  disease  was  caused  by  a  form  of  coccus,  which  when  in- 
oculated in  pure  culture  reproduced  the  disease.  Later,  Cordua  found  in 
the  lesions  a  coccus  resembling  in  its  mode  of  growtb  Staphylococcus  pyo- 
genes albus,  but  the  individual  cocci  were  several  times  larger  tban  Staphylo- 
coccus albus.  He  also  reproduced  the  disease  by  inoculation  of  cultures  on  his 
own  person. 

The  disease  is  one  very  commonly  observed  in  dispensary  practice  in  cities, 
and  affects  chiefly  those  who  handle  fish,  shellfish,  game,  and  meat — i.  e.,  cooks, 
butchers,  cleaners,  and  handlers  of  fisb  and  game,  oysters,  etc.  The  dis  - 
begins  as  a  patch  of  infiltration  on  a  finger  or  knuckle,  and  spreads  toward  the 
hand.  Sometimes  several  fingers  or  the  whole  hand  as  far  as  the  wrist  may 
be  the  seat  of  the  lesion.  The  inflamed  patches  are  bright  red  or  bluish  red. 
swollen,  elevated,  sharply  defined  from  the  surrounding  skin,  and  tender.  The 
disease  may  last  for  days,  or  even  a  fortnight  or  longer.  Suppuration  does 
not  occur.  Itching  and  burning  are  present.  The  affection  presents  some 
resemblance  to  mild  degrees  of  frostbite  of  the  fingers,  but  the  redness  is  more 
sharply  defined,  and  spreads  by  continuity  of  structure,  nor  does  ulceration 
take  place.  The  occupation  of  the  individual  uives  valuable  aid  in  the  diag- 
nosis. 


144  SPECIAL   DISEASES    OE   WOUNDS 

GLANDERS 

Synonyms. — Farcy;  German,  Rotz;  French,  Morve;  Farcin;  Malleus 
humidus. 

Glanders  is  an  infectious  and  contagious  disease  occurring  chiefly  in  horses, 
and  characterized  by  the  formation  of  nodules  of  granulation  tissue  on  the 
mucous  membrane  of  the  respiratory  tract  and  upon  the  skin,  containing  the 
bacilli  of  the  disease.  The  nodules  break  down  into  ulcers.  Lymphangitis 
and  embolic  infection  of  distant  organs  are  a  regular  accompaniment  of  the 
general  infection.  It  is  communicable  to  man  and  also  to  most  of  the  domes- 
ticated animals,  but  not  to  the  ox.  The  cause  of  the  disease  is  a  rod-shaped 
bacillus  about  1-2  ^  in  length,  with  rounded  ends.  The  bacilli  are  nonmotile, 
and  do  not  produce  spores.  They  are  quite  sensitive  to  heat  and  to  antiseptics, 
and  are  killed  by  drying  after  two  weeks. 

The  best  culture  material  is  blood  serum  at  body  temperature. 

According  to  Muir  and  Eichie,  the  bacilli  may  best  be  stained  in  carbol-thionin 
blue  stock  solution  1  gm.,  thionin  blue  in  100  c.c,  carbolic  acid  of  a  strength 
1-40.  Dilute  1  part  with  3  parts  of  water  and  filter.  Stain  sections  for  five 
minutes  or  upward.  Wash  very  thoroughly  in  water  to  jDrevent  later  deposit  of 
crystals.  Decolorize  with  very  weak  acetic  acid  (a  few  drops  to  a  glassful  of 
water).  Wash  thoroughly  in  water.  Dehydrate  and  clear  with  anilin  oil  and  xylol 
equal  parts  and  then  with  xylol.  This  bacillus  does  not  stain  with  Grain's  method. 
(Ernst.)1 

In  acute  cases  the  bacilli  can  sometimes  be  isolated  from  the  blood  a  few 
days  before  death.  Thus,  Ewing  and  Coleman  report  a  case  of  acute  glanders 
in  man  with  extensive  involvement  of  the  lungs  in  which  bacilli  were  isolated 
from  the  blood  three  days  before  death.  Xoniewitch  reports  the  same  of  fatal 
cases  in  horses.  The  bacilli  were  found  usually  within  the  leucocytes.  Mod- 
erate leucocytosis,  13,000,  has  also  been  observed. 

Diagnosis. — A  ready  and  simple  method  of  making  the  diagnosis  in  a  sus-. 
pected  case  of  glanders  is  to  inoculate  the  discharge  or  scrapings  from  the 
suspected  lesion  into  the  subcutaneous  tissues  of  the  abdomen  of  a  male  guinea 
pig.  The  testicles  of  the  animal  will  become  much  enlarged  within  twelve 
hours  to  three  days,  if  the  bacilli  are  present ;  and  glanders  bacilli  may  be  dem- 
onstrated in  the  testes  themselves  as  well  as  abscesses  in  some  cases.  Another 
test  for  the  presence  of  the  disease  consists  in  injecting  into  the  tissues  of  a 
horse  suspected  of  having  the  disease  a  substance  known  as  mallein,  prepared 
from  the  filtered  cultures  of  the  bacillus  of  glanders  grown  upon  artificial 
media  and  containing  the  toxins  of  the  disease,  but  no  bacilli.  If  a  suitable 
quantity  of  this  material  be  injected  into  the  tissues  of  an  animal  or  man 
affected  with  glanders,  a  rise  of  temperature  occurs,  amounting  in  the  case  of 
the  horse  to  2°  C.  or  more.  This  test  is  said  to  be  accurate  in  from  seventy- 
1  "International  Text-Book  of  Surgery."     Warren  Gould. 


GLANDERS  L45 

five  to  ninety  per  cenl  of  cases.     In  the  horse  as  well  as  in  man  the  disease 
occurs  in  an  acute  and  a  chronic  form. 

Symptoms. — The  symptoms  and  course  of  the  disease  in  the  horse  are  thus 
descrihed  by  Youatl : 

The  curliest  local  symptom  is  a  nasal  discharge,  which  consists  of  an  increased 

secretion,  small  in  quantity,  and  flowing  constantly.  It  is  of  an  aqueous  character. 
mixed  with  a  little  mucus.  It  is  qoI  sticky  when  t'n-t  recognized,  but  becomi 
afterwards,  having  a  peculiar  viscidity  and  glueyness.  The  discharge  soon  increases 
in  quantity,  and  in  the  advanced  stages  becomes  discolored,  bloody,  and  offen 
On  the  other  hand,  the  disease  may  continue  for  many  months,  or  even  for  two 
or  three  years,  unattended  by  any  other  symptom,  and  yet  the  horse  he  decidedly 
glandered.  The  glands  under  the  jaw  soon  become  enlarged,  and  are  generally 
observed  on  the  same  side  ns  that  on  which  the  nostril  is  affected;  the  swelling  at 
first  may  he  somewhat  large  and  diffused,  hut  this  subsides  in  a  great  measure 
and  leaves  oik-  or  two  glandular  enlargements,  which  become  closely  adherent  to 
the  jaw-hone.  The  mucous  membrane  of  the  nose  becomes  of  a  dark-purplish  hue, 
or  almost  of  a  leaden  color — never  the  faint  pink  blush  of  health,  or  the  intense 
and  vivid  red  of  usual  inflammation.  Spots  of  ulceration  will  probably  appear 
on  the  membrane  covering  the  cartilage  of  the  nose;  these  ulcers  arc  of  a  circular 
form,  deep  and  with  abrupt  and  prominent  edges,  and  become  larger  and  more 
numerous,  obstructing  the  nasal  passages,  and  causing  a  grating  or  choking  noise 
in  hreathing.  The  disease  extends  upward  into  the  frontal  sinuses,  and  the  integu- 
ment of  the  forehead  becomes  thickened  and  swollen,  causing  peculiar  tenderness. 
The  absorbents  about  the  face  and  neck  now  become  implicated,  constituting  farcy; 
these  enlarge  and  soon  ulcerate.  The  absorbents  on  the  inside  of  the  thigh,  and 
then  the  deep  absorbents  of  both  hind  legs,  are  next  involved,  causing  the  parts 
to  swell  to  a  great  size,  and  to  become  stiff,  hot,  and  tender.  The  constitutional 
symptoms  are  loss  of  flesh,  impaired  appetite,  failing  strength,  and  more  or  less 
urgent  cough:  the  belly  is  tucked  up;  the  coat  is  unthrifty  and  readily  comes  off. 
The  animal  soon  presents  one  mass  of  putrefaction,  and  dies  exhausted. 

Glanders  in  Man. —  hi  man  the  characteristic  feature  of  the  disease  i-  the 
formation  of  nodules  chiefly  upon  the  mucous  membrane  of  the  respiratory 
trad  ami  upon  the  skin  of  various  regions;  the  nodules  are  small  at  first, 
varying  in  size  from  that  of  a  small  bird  shot  to  that  of  a  pea.  They  are 
whitish  or  yellowish  in  color,  are  surrounded  by  an  inflamed  border,  are 
sometimes  unibilicaled,  and  tend  rapidly  to  break  down,  forming  ulcers  which 
spread  in  size  and  depth.  Secondary  involvement  of  distanl  organ-  takes 
place  apparently  through  the  blood  current;  and  the  abdominal  viscera,  the 
lungs,  the  hone-,  the  testes  may  all  he  involved  with  the  production  of  nodules 
and  of  diffuse  infiltrations.  When  the  skin  is  the  seat  id'  the  infection  a 
similar  process  occurs,  nodules  are  formed  which  rapidly  soften,  and  are 
followed  by  progressive  and  destructive  ulceration.  The  nodules  commonly 
form  along  the  eourse  of  the  lymphatic  channels  I  farcy  buds).  In  man  the 
disease  may  run  a  very  rapid  course  under  the  guise  of  a  septicemia  or  septic 
11 


146  SPECIAL   DISEASES    OF   WOUNDS 

pneumonia  with  typhoid  syinjDtoms,  and  death  may  occur  in  a  few  days  or  a 
fortnight. 

Modes  of  Infection. — The  diagnosis  may  be  difficult  or  impossible  without 
a  clew  furnished  by  the  occupation  of  the  individual  or  a  history  of  exposure 
to  infection  from  a  diseased  animal.  Coachmen,  farriers,  cavalrymen,  and 
those  in  general  who  have  much  to  do  with  horses  are  most  often  attacked. 
The  modes  of  infection  are  various.  The  infectious  material  may  be  blown 
or  coughed  into  the  face  by  the  diseased  animal,  or  minute  wounds  may  be 
infected  by  handling  the  horse  or  his  harness  or  clothing.  Thus  the  infection 
may  take  place  through  or  near  the  mucous  membrane  of  the  nose  (glanders) 
or  through  the  external  integument  (farcy).  According  to  these  two  different 
modes  of  infection  and  progress  the  disease  may  be  divided  into  two  types — 
glanders  and  farcy — each  acute  and  chronic,  although  combinations  of  the 
two  types  of  the  disease  may,  of  course,  occur. 

Acute  Glanders. — In  acute  cases  the  period  of  incubation  is  three  or  four 
days.  The  disease  begins  with  general  malaise,  a  febrile  movement,  and  gen- 
eral pains.  There  is  swelling,  redness,  and  often  lymphangitis  at  the  site  of 
inoculation.  Within  a  few  hours  or  a  day  nodules  are  formed  in  the  mucous 
membrane  of  the  nose ;  these  rapidly  ulcerate  and  purulent  discharge  occurs 
from  the  nares.  Secondary  involvement  of  the  skin  of  the  face  and  of  dis- 
tant parts  occurs  and  a  pustular  eruption  is  developed  upon  the  face  and  on 
the  extremities,  notably  about  the  joints.  The  pustular  eruption  goes  on  to 
ulceration,  and  the  ulcers  may  become  necrotic  and  offensive.  The  disease 
has  been  mistaken  for  small-pox.  The  lymphatics  of  the  neck  are  much  swollen. 
Acute  purulent  arthritis  of  the  larger  joints  as  a  metastatic  process  occurs  in 
some  cases.  The  joint  becomes  red,  swollen,  painful,  tender,  and  distended 
with  purulent  fluid.  Secondary  involvement  of  the  lungs  produces  a  septic 
pneumonia,  and  the  abdominal  organs  and  kidneys  often  become  involved 
through  the  blood  current.  Death  is  invariable  in  this  form  of  the  disease, 
usually  in  less  than  a  fortnight. 

Chronic  Glanders. — The  chronic  form  of  the  disease  in  man  is  rather  rare, 
and  may  be  very  hard  to  recognize.  There  is  not  the  same  tendency  to  ulcer- 
ation which  occurs  in  acute  cases,  and  the  lesions  resemble  tuberculosis  in  that 
they  tend  to  undergo  caseation.  They  may  be  confounded  also  with  gummata 
or  even  with  actinomycosis.  The  localization  of  the  process  in  the  nose  is  by 
no  means  as  frequent  in  man  as  in  the  case  of  the  horse.  The  process  may 
last  for  months  or  even  years ;  a  mortality  of  fifty  per  cent  attends  this  form 
of  the  disease.  The  diagnosis  depends,  as  in  acute  cases,  upon  recognition  of 
the  bacilli  in  the  discharge,  in  scrapings  or  sections  of  tissue,  and  in  inoculation 
of  animals,  as  before  mentioned. 


CHAPTER    IV 

SURGICAL  TUBERCULOSIS  AND  DIAGNOSIS  OF  DISEASES  OF  JOINTS 

SURGICAL    TUBERCULOSIS 

The  forms  of  tuberculosis  interesting  to  the  surgeon  are,  especially:  Tuber- 
culosis of  the  skin  and  mucous  membranes;  of  the  lymph  glands;  of  the  tendons 

and  tendon  sheaths,  bursa  and  muscles;  of  the  bones  and  joints;  of  serous  mem- 
branes, notably  of  the  peritoneum  and  pleura;  of  the  genito-urinary  organs,  the 
breast,  the  thyroid  gland,  and  the  testicles.  (For  tuberculosis  of  serous  mem- 
branes and  of  organs,  see  Regional  Surgery.) 

Clinical  Diagnosis  of  Tuberculosis. — The  clinical  diagnosis  of  tuberculosis  is 
usually  possible  without  the  identification  of  the  tubercle  bacillus,  but  there 
are  a  number  of  conditions  in  which  a  recognition  of  tubercle  bacilli — either  in 
discharges,  in  excretions,  or  in  tissues — is  almost  indispensable  for  a  positive 
diagnosis,  and  necessary  before  intelligent  surgical  treatment  can  be  planned. 
I  shall  accordingly  dwell  upon  the  methods  of  examination  of  various  kinds 
of  material  for  tubercle  bacilli  at  some  length.  While  tubercle  bacilli  exist  in 
all  the  lesions  of  the  disease,  yet  under  certain  conditions  their  recognition  is 
difBcull  by  microscopic  examination,  and  we  are  then  obliged  to  resort  to  inocu- 
lation  of  the  suspected  material  into  the  bodies  of  susceptible  animals  (usually 
guinea  pigs  are  selected)  in  order  to  demonstrate  conclusively  the  existence  of 
the  disease. 

Laboratory  Identification  of  Bacillus  Tuberculosis. — The  tubercle  bacillus  may 
be  recognized  by  its  staining  reactions  under  the  microscope  and  by  its  behavior 
in  culture  media.     The  following  technical  description  is  that  of  Ernst:  ' 

The  bacillus  of  tuberculosis  occurs  in  all  lesions  of  the  disease.  It  is  a  small 
rod,  on  the  average  from  2.5  to  3.5  /x  in  length  and  <>.:?  /t  in  breadth.  It  occurs 
singly  or  in  pairs,  arranged  either  end  to  end  or  like  the  arms  of  the  letter  Y.  It 
is  Qonmotile.  The  unstained  portions  of  the  rod  have  been  by  some  supposed  to 
be  spores,  hut  this  is  not  generally  accepted.  It  does  not  grow  upon  ordinary 
gelatin  or  upon  ordinary  nutrient  agar.  It  docs,  however,  develop  upon  both 
of  lliese  media  if  Erom  six  to  eight  per  cent  of  glycerin  have  been  added  to 
them.  Its  best  growth,  however,  is  found  upon  blood-serum  at  the  temperature 
of  the  body.  On  this  medium  its  colonies  present  a  characteristic  appearance. 
They  are  seen  first  as  small  brownish-yellow  dots,  and  never  before  the  eighth  or 

1  H.  C.  Ernst,  "International  Text-Book  of  Surgery/'  vol.  i.  p.  35.     Warren  Gould. 

1  17 


148         SURGICAL   TUBEKCULOSIS   AND   DISEASES    OF   JOINTS 

ninth  day.  They  increase  in  size,  coalesce,  and  form  a  heavy,  wrinkled,  dirty-brown 
or  cream-colored  layer  extending  outward  three  or  four  lines  on  each  side  of  the 
needle-track,  and  in  undisturbed  cultures  grow  upon  the  surface  of  the  water  of 
condensation,  leaving  the  fluid  below  perfectly  clear.  Once  seen,  these  colonies  are 
almost  unmistakable  for  anything  else.  The  growth  upon  potato,  which  is  sometimes 
seen,  but  not  always,  presents  similar  characteristics.  The  bacillus  is  of  slow  growth, 
develops  only  at  the  temperature  of  the  body,  does  not  liquefy  gelatin,  probably 
does  not  produce  spores,  produces  no  gas  or  odor,  stains  with  difficulty  with  the 
ordinary  anilin  colors,  decolorizes  with  equal  difficulty,  and  produces  tuberculosis 
upon  inoculation  in  all  susceptible  animals.  The  difficulties  in  cultivating  the 
bacillus  of  tuberculosis  would  present  an  almost  insuperable  obstacle  to  the  diag- 
nosis of  tuberculous  processes  by  this  method.  Fortunately,  however,  Ehrlich 
showed  that  this  bacillus  has  a  special  staining  reaction  by  which  it  may  be  differ- 
entiated from  any  others  with  which  it  is  likely  to  be  confounded.  Taking  advan- 
tage of  the  resistance  of  this  bacterium  to  the  decolorizing  action  of  the  mineral 
acids,  Koch  and  Ehrlich  worked  out  a  differential  stain,  than  which  no  better 
method  has  ever  been  suggested  for  the  detection  of  small  numbers  of  the  bacilli 
in  suspected  material.    For  cover-glasses  this  method  is  as  follows : 

1.  Cover-glasses  prepared  in  the  usual  way  are  stained  overnight — better  for 
twenty-four  hours — in  anilin-water  fuchsin  (or  gentian  violet).  2.  Transfer  at  the 
end  of  that  time  to  nitric  acid  (1:1)  for  a  few  seconds.  3.  Place  in  sixty  per  cent 
alcohol  for  one  minute  to  complete  decolorizing.  I.  Wash  in  water.  5.  Stain  in 
watery  methylene  blue  (or  vesuvin,  if  gentian  violet  was  the  first  stain  used)  for 
one  to  two  minutes;  wash  thoroughly;  dry  carefully;  mount  in  oil  of  cedar  or 
Canada  balsam. 

Sections  are  stained  in  precisely  the  same  way,  with  the  exception  that  in  place 
of  the  nitric  acid,  1  part  to  I,  a  little  stronger  bath  of  nitric  acid  is  used,  1  part 
to  3,  because,  the  sections  being  thicker  than  the  film  on  the  cover-glass,  a  some- 
what stronger  decolorizing  agent  is  necessary.  Of  course,  after  the  washing  fol- 
lowing the  use  of  the  methylene  blue,  the  sections  are  to  be  dehydrated,  cleared  in 
oil  of  cedar,  and  mounted  in  Canada  balsam. 

The  efficiency  of  this  stain  lies  in  the  fact  that  the  nitric  acid  appears  to  exert 
some  direct  coagulant  (  ?)  action  upon  the  capsule  of  the  bacillus  itself.  This 
action  is  practically  instantaneous,  and  results  in  placing  the  capsule  in  such  a 
condition  that  it  resists  the  further  decolorizing  action  of  the  nitric  acid,  so  that 
the  bacillus  remains  stained.  This  is  not  true  with  other  bacilli ;  all  other  bacteria 
are  completely  decolorized,  except  the  bacillus  of  leprosy  and  the  smegma  bacillus; 
and  if  the  source  of  the  material  allows  any  possibility  of  confusion  with  these  two, 
the  method  of  differentiation  already  given  will  serve  to  put  an  end  to  any  doubt. 
(See  Tubercle  Bacilli  in  the  Urine.) 

The  method  as  given  by  Koch  suggests  the  use  of  gentian  violet  as  the  first 
stain  (with  fuchsin  as  the  second  choice)  and  vesuvin  as  the  contrast  stain  (with 
methylene  blue  as  the  second  choice),  the  result  of  which  would  be,  of  course,  a 
blue-stained  body  upon  a  brown  ground;  while  the  method  preferred  here  gives 
red-stained  rods  upon  a  blue  ground.  This  is  the  result  that  has  been  found  by 
far  the  most  useful,  for  it  is  much  more  easy  for  the  eye  of  the  average  student 
to  detect  a  minute  red  body  upon  a  blue  ground  than  it  is  to  find  a  minute  blue 
body  upon  a  brown  ground.     Much  objection  is  constantly  raised  to  this  method 


SURGICAL   TUBERCULOSIS  1  I!) 

of  staining  because  of  the  time  thai  musi  elapse  before  the  material  is  ready  for 
the  microscope,  and  innumerable  Bhorl  ready  methods  have  beeE  suggested,  uol  om- 
ul' which  is  as  reliable  as  tin's,  bui  many  of  which  are  much  more  used. 

The  most  common  of  these  is  the  Bo-called  Ziehl's  method.  In  this  method,  as 
in  the  others,  advantage  is  taken  of  the  resistance  of  the  bacillus  of  tuberculosis 
to  decolorizing  agents.  As  in  the  firsl  method  given  the  anilin  oil  is  used  as  a 
mordant  to  intensify  the  action  of  the  firsl  -tain,  bo  in  this  method  the  aid  of  a 
still  stronger  mordanl  is  sought  and  Found  in  carbolic  arid.  The  firsl  procedure 
in  the  Ziehl-Nielsen  method,  which  i-  applicable  only  to  cover^glasses,  is  as  follows: 

Cover-glasses   prepared  after  the  usual   thod  arc  stained   in  carbol   fuchsiu   for 

thirty  minute-  (this  time  may  be  shortened  to  ten  minutes  by  warming  the  stain- 
ing fluid);  decolorize  in  sulphuric  acid  (1  part  to  I)  for  a  few  Beconds;  wash  in 
water;  a  contrast  stain  is  obtained  by  watery  methylene  blue  for  two  or  three  min- 
utes; the  cover-glasses  are  then  thoroughly  washed  in  water,  carefully  dried,  and 
mounted.  In  this  method,  as  there  is  a  stronger  mordant  used  in  the  carbolic  acid, 
so  there  is  a  stronger  decolorant  used  in  sulphuric  acid.  Experience  has  demon- 
strated that  while  this  stain  may  he  useful  for  showing  the  presence  of  large 
numbers  of  bacilli,  it  cannot  he  relied  upon  when  there  are  hut  \'<w.  Of  this 
method,  as  of  all  the  short  methods  yet  presented,  it  may  be  said  that  if  one 
finds  rods  stained  red  on  a  blue  ground,  the  presence  of  the  bacilli  may  be  acknowl- 
edged :  yet  if  such  rods  are  not  found,  the  absence  of  the  bacilli  cannot  with  safety 
he  asserted. 

Gabbet's  method  of  staining  is  one  frequently  used,  combining  the  decolorizing 
and  the  second  stain.  1.  Stain  cover-glasses  with  carbol-fuchsin,  hot,  for  one  min- 
ute. "2.  Wash  in  water.  3.  One  half  minute  in  Gahhet's  methylene  blue  (methylene 
blue,  2;  sulphuric  acid,  25;  water,  75).    4.  Wash  thoroughly,  dry.  and  mount. 

In  examining  suspected  material  for  purposes  of  diagnosis  in  tuberculosis,  cover- 
glass  preparations  are  to  he  made  in  quite  large  numbers,  and  thoroughly  studied 
after  being  stained  by  one  or  more  of  the  methods  suggested  :  but  inoculation  experi- 
ments are  sometimes  successful  when  the  microscopic  examination  fails,  so  that  re- 
course should  be  had  to  these  inoculation  experiments  if  the  matter  of  diagnosis  is 
one  of  importance  and  the  microscopic  examination  has  failed  to  demonstrate  the 
bacilli.  Inoculation  experiments  are  more  commonly  necessary  in  the  diagnosis  of 
surgical  tuberculosis  than  in  other  forms  of  the  disease.  The  bacillus  being  more 
often  present  in  the  granulations  and  lining  membranes  of  abscess  cavities,  it  is  to  be 
looked  for  especially  in  these  tissues  rather  than  in  the  contained  fluid. 

Clinical  Diagnosis  of  Surgical  Tuberculosis. — The  clinical  diagnostic  features 
of  surgical  tuberculosis  in  general  arc  the  formation  of  tubercular  tissue  in  the 
form  of  miliary  and  submiliary  tubercles,  or  of  larger  area-  of  tubercular  infil- 
tration in  tissues  and  organs;  a  tendency  of  the  tubercle  tissue  to  undergo 
caseation  and  subsequent  softening  and  liquefaction;  a  very  chronic  course; 
absence  of  the  signs  of  acute  inflammation;  a  tendency  to  invade  neighboring 
structures  and  to  progress  along  the  linos  of  least  resistanc< — notably  along 
intermuscular  planes  by  the  force  of  gravity — or  to  break  through  the  articular 
end-  of  bones  into  joinl  cavities,  and  in  some  instances  to  produce  a  general 
infection  of  the  organism. 


150         SURGICAL   TUBERCULOSIS   AND   DISEASES    OE   JOINTS 

Tuberculosis   of   the   Skin 

Lupus. — The  most  common  form  of  tuberculosis  of  the  skin  is  lupus.  The 
disease  commonly  occurs  in  youth  and  early  adult  life.  It  affects  the  face  more 
often  than  the  extremities,  more  rarely  the  trunk;  the  arms,  from  the  elbow 
to  the  fingers,  more  often  than  the  legs ;  the  dorsal  surfaces  and  neighbor- 
hood of  joints  rather  than  the  palms  or  soles.  Upon  the  face,  the  nose  is  the 
most  frequent  starting  point  of  lupus,  and  the  ala  of  the  nose  is  often  first 
affected. 

Characteristics. — The  characteristic  sign  of  the  disease  is  the  lupus 
nodule,  a  circumscribed  rounded  infiltration  of  the  true  skin,  of  a  reddish- 
brown,  pink-brown,  or  yellow-brown  color,  and  an  "  apple-jelly,"  or  semitrans- 
lucent,  appearance,  of  varying  size,  rather  soft  in  consistence.  Upon  pressure 
the  color  of  the  nodule  becomes  paler,  but  some  color  remains.  The  nodule  is 
on  a  level  with  the  surrounding  skin  (Lupus  maculosus),  and  may  remain  so. 
Such  nodules  vary  in  size  from  that  of  the  head  of  a  small  pin  to  that  of  a 
No.  2  shot. 

Course. — The  disease  pursues  a  very  chronic  course,  and  the  surface  of  the 
nodule  after  a  time  becomes  covered  with  dry  scales  (Lupus  exfoliativus).  De- 
generative changes  take  place  in  the  nodule;  it  breaks  down  and  ulcerates  (Lu- 
pus exulcerans,  Lupus  excedens),  or  undergoes  atrophy  and  is  replaced  by  cica- 
tricial tissue.  The  presence  of  one  nodule  is  usually  followed  by  the  develop- 
ment of  others  in  the  neighborhood.  The  disease  is  prone  to  advance  at  the 
periphery,  while  the  older  portions  undergo  atrophy  or  more  or  less  complete 
cure.  If  many  nodules  coalesce,  a  considerable  mass  of  tuberculous  tissue  may 
be  formed,  with  cell  infiltration  of  the  deeper  structures  (Lupus  hypertrophi- 
cus).  Very  often  the  several  processes  go  on  hand  in  hand  in  the  same  lesion. 
The  ulcerative  form  of  lupus  causes  notable  destruction  of  tissue.  On  the  face, 
the  nose  may  be  more  or  less  completely  destroyed.  The  ala?,  the  tip  of  the 
nose,  and  the  cartilages  suffer  rather  than  the  bones,  and  the  nose  has  the 
appearance  of  having  been  cut  off.  Syphilis,  on  the  other  hand,  produces  bone 
destruction  and  a  sunken  or  so-called  saddle  nose.  The  lips,  the  cheeks,  the 
forehead  may  all  be  involved  with  the  production  of  hideous  deformities.  The 
ulcers  are  commonly  covered  with  crusts  made  up  of  cheesy  material,  broken- 
down  tubercle  tissue,  and  the  dried  discharges  of  ordinary  purulent  infection — 
a  regular  coexistent  lesion  in  these  cases. 

Diagnostic  Features  of  Lupus. — The  characteristic  nodules  in  the  skin, 
the  chronic  course,  the  tendency  to  serpiginous  advance  of  the  disease,  the  for- 
mation of  cicatricial  tissue  in  the  older  portions  of  the  lesion  while  new  nodules 
and  ulcerations  are  present  at  the  advancing  border,  the  situation,  are  the  im- 
portant diagnostic  features.  The  lesions  are  usually  not  painful.  Upon 
removing  the  crust  from  ulcerated  areas,  minute  grayish  or  white  points  may 
be  distinguished  upon  the  raw  surface;  these  are  miliary  or  submiliary  tuber- 
cles undergoing  degenerative  changes.     They  bear  a  slight  resemblance  to  the 


SURGICAL   TUBERCULOSIS  L51 

epithelial  masses  3een  upon  the  surface  of  an  ulcerating  epithelioma.  These 
hitter,  however,  can  readily  be  expressed  from  the  raw  surface,  and  under  the 
microscope  are  easily  seen  to  consisl  of  masses  of  epithelial  cells.  It  is  to  be 
remembered  that  epitheliomatous  degeneration  of  areas  long  affected  by  Lupus 
is  n<»t  an  uncommon  occurrence. 

Verruca  necrogenica  (Anatomical  Tubercle). — This  variety  of  tuberculosis 
of  the  skin  is  due  to  direct  in  feci  ion.  The  disease  occurs  most  commonly  upon 
the  dorsal  surfaces  of  the  fingers  and  hands  of  pathologists  and  their  assistants. 
A  red  elevated  nodule  appears  at  the  site  of  inoculation,  and  slowly  increases 
in  size;  the  nodule  is  rather  firm  on  palpation,  usually  painless,  or  bul  slightly 
painful.  The  central  portion  soon  breaks  down,  creating  a  small  ulcer  covered 
by  a  scab;  upon  removing  this  several  small  orifices  are  seen  in  the  tubercular 
granulation  tissue;  from  these  a  little  pus  may  be  made  to  exude  by  pressure. 
Later,  papillary  outgrowths  fake  place,  producing  a  wartlike  appearance.  The 
occupation  of  the  individual,  the  very  chronic  course,  and  the  characteristic 

appearance^,  render  the  diagnosis  easy. 

Tuberculosis  verrucosa  cutis. — ruder  this  name,  Riehl  and  Paltauf,  in  1886, 
described  a  tuberculosis  of  the  skin  characterized  by  the  formation  of  patches 
of  tubercular  infection  of  the  cutaneous  surface  varying  in  size  from  three 
fourths  of  an  inch  to  two  inches  in  diameter.  The  disease  is  very  chronic,  and 
the  infected  areas  are  sensitive  and  sometimes  painful.  As  described,  the  patch 
exhibits  three  zones:  an  outer  red  border  of  erythema,  within  that  a  circle  of 
small  pustules,  often  covered  by  scales,  and  a  central  area  covered  by  papillary 
outgrowths. 

Secondary  Tubercular  Infections. — Secondary  tubercular  infections  of  the 
skin  occur  as  the  result  of  the  spread  of  deep-seated  tubercular  lesions,  notably 
of  the  lymph  nodes,  the  bones,  and  the  joints.  Softening  of  the  tubercular 
tissue  is  followed  by  the  formation  of  a  tuberculous  abscess  which  tends  to 
advance  by  pressure  toward  the  surface.  The  skin  finally  becomes  infected 
from  -within,  softens,  and  breaks  down.  Tuberculous  material  is  discharged 
and  a  tubercular  ulcer  or  sinus  remains,  according  to  local  conditions.  The 
appearance  of  these  lesions  is  characteristic.  The  skin  ediics  of  the  orifice 
are  rounded  or  irregular  in  contour,  have  a  worm-eaten  appearance,  are  of  a 
blue  or  purple  color,  and  a  soft,  friable  consistence  when  the  perforation  is 
recent.  Often  several  orifices  exist  separated  by  bridges  of  blue,  thinned-oul 
and  friable  skin.  The  cavity  is  lined  by  pale  granulation  tissue,  showing  here 
and  there  upon  its  surface  yellowish  areas  of  caseous  material. 

After  a  time  exuberant  tuberculous  granulations  are  prone  to  form  and  to 
become  elevated  above  the  level  of  the  skin.  The  appearance  of  these  at  the 
orifice  of  a  tuberculous  sinus  has  been  likened  to  a  fold  «»f  prolapsed  mucous 
membrane.  Cicatricial  tissue  in  abundance  is  thrown  oul  by  the  surround- 
ing tissues,  and  after  a  time  these  orifices  come  to  l>o  surrounded  by  a  dense, 
bard,  fibrous  wall,  and  later,  by  the  contraction  id'  such  tissue,  the  orifice 
comes   to   be   depressed    below    the   level    of    the    skin.      The    discharge    from 


152         SUEGICAL   TUBERCULOSIS   AND   DISEASES    OF   JOINTS 

such  sinuses  varies  in  character.  Upon  the  rupture  of  a  tuberculous  abscess 
a  rather  pale  yellow  or  white  creamy  material  escapes,  containing  cheesy 
masses. 

This  so-called  tuberculous  pus  is  of  characteristic  appearance;  it  is  found 
under  the  microscope  to  consist,  not  of  pus  cells,  but  of  granular  material  con- 
taining much  fat — the  result  of  the  degeneration  of  the  tuberculous  granu- 
lations. Tubercle  bacilli  cannot  usually  be  demonstrated  in  the  material,  al- 
though when  inoculated  into  susceptible  animals  tuberculosis  follows.  After 
the  abscess  has  once  emptied  itself  the  discharge  diminishes  in  quantity,  be- 
comes scanty,  often  thin  and  watery.  Secondary  infection  with  pus  microbes 
often  occurs,  and  the  picture  then  changes  to  one  resembling  ordinary  suppura- 
tion with  the  discharge  of  true  pus.  The  bacillus  pyocyaneus  is  a  not  infre- 
quent invader  of  these  sinuses.  The  dressings  are  then  stained  with  the  char- 
acteristic green  discharge,  and  a  musty  odor  is  present. 

Tuberculosis  of  Mucous  Membbane 

Primary  tuberculosis  of  the  readily  visible  mucous  membrane  is  rather  un- 
common. Secondary  infection  of  mucous  membranes  is  common.  Tubercu- 
losis of  the  mucous  membrane  of  the  nose  is  sometimes  the  starting  point  of 
lupus  of  the  face. 

Tuberculosis  of  the  Posterior  Pharyngeal  Wall  and  Soft  Palate. — This  occurs 
occasionally  during  childhood,  puberty,  and  adolescence  among  individuals 
already  the  subjects  of  tuberculosis  of  the  lungs.  Submiliary  tubercles  occur, 
and  break  down  into  shallow  ulcers  with  a  cheesy  base.  Such  ulcerations  may 
be  confounded  with  syphilis.  The  tubercular  process  is,  however,  attended 
by  less  destruction  of  tissue,  is  more  painful,  tends  to  spread  superficially,  and 
to  undergo  later  cicatricial  contraction. 

Tuberculosis  of  the  Tongue. — Tuberculosis  of  the  tongue  occurs  in  individ- 
uals with  tuberculosis  of  the  lungs.  The  ulcer  is  usually  rounded  or  oval,  ten- 
der and  painful,  the  base  covered  with  yellow,  caseous  material  or  with  exuber- 
ant pale,  fungating  granulations.  Infiltration  and  hardening  of  the  base  of 
the  ulcer  may  lead  to  the  suspicion  of  cancer.  The  presence  of  lung  tubercu- 
losis, the  very  chronic  course,  and  the  microscopic  examination  of  fragments 
of  diseased  tissue — removed  by  scraping  or  with  the  knife — serve  to  clear  up 
the  diagnosis. 

Tuberculous  "Ulceration  of  the  Rectum. — A  considerable  proportion  of  all 
cases  of  fistula  in  ano  are  tubercular.  These  fistula?  are  often  associated  with 
tuberculosis  of  the  lungs.  They  are  characterized  by  their  chronic  course;  by 
the  production  of  fungating  granulations ;  often  by  undermining  of  the  mucous 
membrane  of  the  gut ;  by  the  formation  of  ulcerated  areas  of  considerable  size ; 
and  by  the  occurrence  of  burrowing  sinuses,  whose  skin  orifices"  have  the  char- 
acteristic tubercular  appearance.  They  are  very  apt  to  recur,  or  fail  to  heal, 
even  after  thorough  operative  removal.     (See  Rectum.) 


SUKGICAL   TUBERCULOSIS 


153 


Tl   BEBCULOSIS    OJ     THE     Lv.MI'll     GLANDS 

Tuberculosis  of  the  Lymph  Nodes. — One  of  the  commonesl  forms  of  tuber 
cular  disease  is  tuberculosis  of  the  lymph  nodes.  The  condition  was  cbarac 
terized  by  Billroth  as  "  the  daily  bread  of  the  Burgical  clinic."  .\-  i-  th< 
with  oilier  forms  of  tuberculosis,  tubercular  lymphomata  occur  mosl  commonly 
during  childhood,  adolescence,  and  early  adult  life,  bul  ili<j  condition  i-  com- 
iiion  enough  a1  all  ages.  Of  the  superficial  lymphatics,  the  glands  of  the  neck, 
the  cubital,  the  axillary,  and  the  inguinal  and  femora]  glands  are  infected  in 
the  above  order  of  frequency.  The  mediastinal,  mesenteric,  and  retroperitoneal 
lymph  nodes  arc  also  frequently  the  seal  of  tuberculosis,  but  are  of  less  sur- 
gical interest. 

The  infection  may  be  primary,  directly  through   the  lymph  current,   the 
infection  atrium  not  being  apparent;  or  a  catarrhal,  ulcerated,  or  fissured  con- 
dition  of   a    mucous   surface   may 
permit   the   passage  of  the  bacilli. 

In  other  cases  infection  takes  place 
through  the  lymph  channels  from 
an  existent  tubercular  lesion  else- 
where. Infection  through  the  blood 
current  direct  also  may  occur.  The 
tonsils  and  lymphoid  tissue  of  the 
nasopharynx  are  favorite  portals  of 
entry.  Cutaneous  irritations  and 
eruptions  upon  the  face  and  scalp, 
and  carious  teeth,  often  precede 
the  glandular  infection. 

Characteristics  of  Tuberculosis 
of  Lymph  Glands. — The  disease  is 
characterized  by  a  slow,  painless 
enlargement  of  the  affected  glands. 
Early  in  the  disease  the  glands 
are  discrete,  movable,  and  may  re- 
main so  indefinitely.  In  other 
cases  periglandular  inflammation 
occurs;  the  tumors  then  become 
adherent  to  the  surrounding  struc- 
tures and  to  each  other;  they  cease 
to    be    movable,    and     form    smooth 

or  nodular  masses  of  considerable  size.  In  some  cases  caseation  occurs 
without  rupture  of  the  glandular  capsule,  and  calcareous  degeneration  may 
take  place;  in  this  condition  the  tumors  may  remain  quiescent  indefinitely. 
More  commonly  softening  and  perforation  of  the  glandular  capsule  occurs,  and 
results  in  the  formation  of  a  painless,  insensitive,  fluctuating  area,  which  finally 


Fig.  23. — Tuberculosis  of  the  Lymph  Modes  of 
the  Neck.  (NewYork  Hospital,  service  of  Dr. 
Prank  Hartley.) 


154 


SUEGICAL    TUBEKCULOSIS    AND    DISEASES    OE    JOINTS 


perforates  the  skin,  as  already  described.  Signs  of  acute  inflammation  are 
absent.  In  other  instances  a  diffuse  tubercular  inflammation  of  the  subcu- 
taneous connective  tissue  and  of  the  intermuscular  and  fascial  planes  results. 
The  infection  is  also  prone  to  advance  from  one  gland  to  another,  either  slowly 
and  insidiously  or  quite  suddenly.  After  perforation  of  the  skin  has  taken 
place,  a  tubercular  ulcer  or  sinus  remains  behind.  Such  sinuses  may  remain 
open  for  years,  may  heal  from  time  to  time,  only  to  break  down  again,  or 
spontaneous  cure  may  occur,  often  with  the  formation  of  ugly,  puckered  scars. 
Differential  Diagnosis  of  Tubercular  Lymph  Glands. — It  is  necessary  to  dif- 
ferentiate tubercular  lymphomata  from  simple  inflammatory  hyperplasia,  from 

primary  sarcoma  of  the  lymph 
nodes,  from  malignant  lymphom- 
ata, pseudoleukemia,  and  from 
secondary  carcinomatous  infection. 
From  simple  inflammatory  swell- 
ing, not  accompanied  by  suppura- 
tion, the  diagnosis  is  not  always 
easy  from  a  single  observation. 
The  presence  of  a  superficial  source 
of  irritation — an  infected  wound, 
an  ulcer,  an  inflammatory  lesion 
of  the  skin — points  to  a  simple  in- 
flammation. 

In  such  cases  the  enlargement 
of  the  glands  is  moderate ;  the 
glands  are  usually  neither  tender 
nor  painful ;  they  are  freely  mov- 
able. Removal  of  the  superficial 
source  of  irritation  is  followed  by 
diminution  in  the  size  of  the 
glands,  though  some  enlargement 
may  persist  indefinitely.  Such 
glands  may  subsequently  become 
the  seat  of  tuberculosis.  If  after 
removal  of  the  external  source  of 


Fig.  24. — Tuberculosis  of  Cervical  Lymph 
Nodes,  marked  Periglandular  Infiltration. 
(New  York  Hospital,  service  of  Dr.  Frank 
Hartley.) 


irritation     the     enlargement 


con- 


tinues or  increases,  tuberculosis  is  probable.  The  gross  and  microscopic  ap- 
pearances of  the  glands,  after  removal,  are  usually  characteristic,  if  tubercular. 
Bacilli  may  be  found  in  the  earlier  stages ;  after  softening  and  caseation  have 
occurred  their  recognition  may  be  difficult.  Upon  section,  tuberculous  lymph 
glands  vary  in  gross  appearance,  according  to  the  stage  of  the  process.  The 
cut  surface  may  appear  normal  to  the  naked  eye.  Miliary  and  submiliary 
tubercles  may  show  as  grayish-yellow  areas,  distributed  irregularly  throughout 
the  glandular  substance.     Considerable  areas,  or  the  entire  gland,  may  be  in 


SURGICAL    I  UBERCULOSIS 


1 55 


;i   -t.nr  of  caseation,  of  purulent    softening,  or  even   "I"  calcification,   il    the 
process  la  ancient. 

Malignant  Lymphoma,  Pseudoleukemia.-  In  the  early  stages  of  pseudo- 
leukemia, occurring  during  the  second  and  third  decades  of  life,  the  differentia] 
diagnosis  from  tuberculosis  of  the  lymph  glands  is  nol  always  easy.  The  tumor 
masses  of  tuberculosis  are  apl  to  be  <»!'  unlike  consistency  in  differenl  parts; 
areas  of  softening,  alternating  with  indurated  masses  of  periglandular  infil- 
tration  and  with  isolated  nodules  of  varying  size  and  consistence.  The  occur- 
rence of  glandular  tumors  in  an  individual  with  no  predisposition  to  tubercu- 
losis, with  no  signs  of  local  irritation  in  the  vicinity,  and  otherwise  in  apparent 
health,  leads  to  a  suspicion  of  possible  leukemia.  A  steady  increase  in  the 
size  of  the  tumors,  the  sudden  successive  involvemenl  <d'  group  after  group  of 
glands,  and  the  appearance  of  similar  enlargements  in  other  regions,  speaks 
for  pseudoleukemia. 


Fio.    25. — Hodokin's    Disease — Multiple    (ii.amh-i.au    Tumors    m    the    Neck    and    Axii.i.a. 

(New  York  Hospital,  author's  service.) 

The  tumors  of  pseudoleukemia  are  of  uniform  consistency]  they  are  more 
apt  to  produce  pressure  symptoms.  Gradual  and  serious  impairment  of  the 
general  health  occurs  after  a  time,  and  in  seme  instances  an  irregular  and 
intense  fever  makes  its  appearance  from  time  to  time,  lasts  for  hours  <>r  days. 


156         SURGICAL    TUBERCULOSIS    AND    DISEASES    OF    JOINTS 

and  disappears.  Arsenic  in  large  doses  sometimes  causes  notable  diminution 
in  the  size  of  the  pseudoleukemia  tumors.  In  some  instances  a  microscopic 
examination  of  a  gland,  removed  for  the  purpose,  is  necessary  to  clear  up  the 
diagnosis.  The  blood  changes  of  true  leukemia  suffice  to  eliminate  tuberculosis 
as  a  cause  of  the  glandular  tumors  of  the  former  disease.  (For  further  infor- 
mation, see  Tumors  of  Neck.) 

TrBEEcrxosis  of  the   Texdoxs,   Texdox  Sheaths,  Burs^e,  axd  Muscles 

Tuberculosis  of  the  Tendons  and  Tendon  Sheaths. — The  condition  may  be  pri- 
mary in  the  tendons  or  their  sheaths,  or  secondary  to  tuberculosis  of  the  bones 
and  joints  of  the  affected  region.  The  tendons  of  the  forearm  and  hand — flexor 
and  extensor — the  peroneal  tendons  of  the  ankle,  and  the  tendons  about  the 
knee  are  those  most  commonly  involved,  in  the  above  order  of  frequency.  Three 
forms  of  the  disease  are  to  be  distinguished  clinically. 

1.  A  serous  effusion  occurs  in  the  tendon  sheath  which  may  be  sharply 
localized  and  form  a  rounded,  elastic,  fluctuating  swelling  along  the  course  of 
the  tendon — not  to  be  distinguished  from  a  simple  hygroma  (single  or  multiple 
ganglion) — or  the  effusion  may  occupy  the  entire  length  of  the  sheath,  or,  as 
at  the  wrist,  the  tendon  sheaths  of  numerous  tendons  may  be  involved. 

2.  In  the  second  form  there  is  added  to  the  serous  effusion  the  formation 
of  -mall  pedunculated  or  free  fibrinous  masses — the  so-called  rice  bodies — - 
together  with  a  gelatinous  thickening  of  the  wall  of  the  sheath.  A  more  or 
less  elastic  or  fluctuating  swelling  is  thus  produced,  corresponding  in  site  to 
the  course  of  the  affected  tendons. 

3.  The  f ungating  form  is  characterized  by  the  formation  of  tubercular 
granulation  tissue  in  abundance,  and  a  tendency  to  break  down,  with  the 
formation  of  abscesses  and  sinuses.  This  condition  is  progressive,  and  may 
involve  any  neighboring  structures,   including  muscles  and  joints. 

The  serous  and  fibrinous  forms  are  exceedingly  chronic,  they  are  usually 
painless,  except  that  moderate  pain  may  accompany  use  of  the  affected  ten- 
dons. There  is  slowly  progressive  loss  of  power  and  undue  fatigue  of  the 
affected  limb  upon  slight  exertion.  The  disease  may  last  for  many  years 
without  leading  to  serious  inconvenience.  These  two  forms  may  rarely  be 
converted  into  the  third  or  f ungating  form.  Uor  the  special  diagnostic  fea- 
tures of  these  conditions  the  reader  is  referred  to  Regional  Surgery. 

Tuberculosis  of  the  Bursse. — The  bursae  may  become  infected  with  tuber- 
culosis primarily  or  secondarily  to  tuberculosis  of  underlying  bone.  The 
former  variety  may  closely  resemble  tuberculosis  of  the  tendon  sheaths  with 
the  formation  of  rice  bodies.  (See  Tuberculosis  of  Tendon  Sheaths.)  The 
bursa  becomes  enlarged,  its  walls  thickened ;  fluctuation  will  be  more  or  less 
marked  or  nearly  absent,  the  sensation  given  to  the  examining  fingers  being 
rather  that  of  a  sac  containing  semisolid  material.  Incision  is  usually  neces- 
sary to  establish  a  diagnosis  unless  a  sinus  is  present.     In  that  variety  due  to 


SURGICAL   TUBERCULOSIS 


157 


tuberculosis  of  bone  there  is  formed  a  thick-walled  sac  filled  with  tuberculous 
pus  or  granulation  tissue,  giving  a  Bense  of  obscure  fluctuation  There  will  be 
a  history  of  some  pain  and  tenderness  in  the  underlying  bone,  a  chronic  course 
and  the  gradual  formation  of  a  doughy  .-well inn-,  usually  of  rounded  or  ovoid 
Bhape.  Incision  will  establish  the  diagnosis.  The  differentia]  diagnosis  of 
the  inflammations  of  bursas  will  be  found  under  Regional  Surgery. 

Primary  Tuberculosis  of  the  Muscles. — This  is  a  very  rare  condition;  it  has 
been  observed  especially  in  the  muscles  of  the  upper  arm  as  a  dense  hard 
infiltration  of  the  muscular  tissue  resembling  a  new  growth;  the  condition 
eventuates  in  a  characteristic  cold  abscess.  Tuberculosis  of  muscles  and  of 
fascia]  planes  is  a  very  common  condition  secondary  to  tuberculosis  of  bones 
and  joints.  The  diagnostic  features  will  lie  described  under  Regional  Sur- 
gery. 

Tuberculosis  of  Bone 

Occurrence. — Tuberculosis  of  the  bones  is  one  of  the  most  frequent  forms 
of  the  disease.  Most  eouunon  in  eliildhood  and  youth,  but  may  occur  at  any 
age.  The  epiphyseal  ends  of  long  hones  and  the  spongy  tissue  of  short  bones  are 
the  common  seats  of  the 
process;  less  often  the 
shafts  of  long  hones.  Mul- 
tiple foci  do  sometimes 
form  in  various  points  in 
the  medulla  of  a  long  hone, 
and  by  gradual  increase  in 
size  these  may  finally  coa- 
lesce and  form  a  diffuse 
t  uberculous  osteomyelitis ; 
such  a  condition  in  the 
larger  hones  is,  however, 
quite  uncommon. 

Mode  of  Infection. — The 
infection  takes  place  in 
many  instances  primarily 
through  the  blood  in  the 
form  of  an  infected  em- 
bolus. A  circumscribed 
focus  of  tubercular  granu- 
lation tissue  is  produced 
which  undergoes  the  same 
changes  as  tubercle  tissue 
elsewhere.       A    tuberculous 

caries  of  the  bone,  a  sequestrum,  or  a   tuberculous  abscess   may   thus  he  p re- 
duced.    The  foci  may  he  single  or  multiple,  and   are  usually  of  moderate  -1.0. 


Fig.  26.  —Tuberculosis  of  the  First  Phalanx  of  Index 
Finger,  with  Sim-is.  (Spina  ventosa,  author's  collec- 
tion.) 


158         SURGICAL   TUBERCULOSIS    AND   DISEASES    OF   JOINTS 


The  process  is  very  prone  to  extend  into  the  neighboring  joint  or  to  perforate 
the  cortical  layer  and  infect  the  overlying  periosteum  and  soft  parts.  In 
certain  situations,  notably  in  the  phalanges  of  the  fingers  of  children — less 
commonly  in  the  shafts  of  the  longer  bones  of  children  and  adults — there 
occurs  a  tuberculous  osteomyelitis  which  results  in  gradual  absorption  of  the 
cortical  layer  of  bone,  while  irritation  of  the  overlying  periosteum  causes 
the  production  of  new  bone.  In  the  fingers  a  spindle-shaped  enlargement 
of  the  affected  phalanx  occurs ;  and  in  the  shafts  of  the  larger  bones — notably 
the  tibia — localized  swellings  are  produced  (Spina  ventosa). 

Course. — The  course  of  bone  tuberculosis  is  exceedingly  chronic.    The  general 
health  is  often  but  slightly  affected.    Fever  may  occur  from  time  to  time,  but  the 

temperature  is  not  greatly 
elevated.  So  long  as  the 
tubercular  process  remains 
confined  to  the  interior  of 
the  bone  the  signs  and 
symptoms  are  either  absent 
or  slight.  Pain  is  not  a 
marked  symptom.  Tender- 
ness may  be  present  on  per- 
cussion over  the  affected 
area.  Invasion  of  the  peri- 
osteum is  accompanied  by 
pain,  tenderness,  and  ap- 
parent enlargement  of  the 
bone,  with  edema  of  the 
overlying  soft  parts.  Inva- 
sion of  a  joint  is  attended 
by  the  signs  of  joint  tu- 
berculosis to  be  described. 
Perforation  of  the  perios- 
teum and  invasion  of  the 
overlying  soft  parts  and 
skin  are  indicated  by  the 
formation  of  a  cold  abscess 
or  by  the  presence  of  a  tu- 
bercular ulcer  or  sinus.  A 
probe  introduced  into  such 
a  cavity  may  meet  with 
carious  bone  or  pass  direct- 
ly through  a  perforation 
into  the  medullary  cavity,  or  if,  as  often  happens,  the  tuberculous  abscess  has 
traveled  along  intermuscular  planes  by  gravity,  from  a  distance,  no  diseased 
bone  can  be  reached,  and  the  diagnosis  must  be  arrived  at  by  other  means. 


Fig.  27. — X-ray  Picture  of  Early  Tuberculosis  of  the 
Elbow  in  a  Child,  Showing  Slight  Destruction  of  the 
Anterior  Surface  of  the  Humerus  just  above  the 
Elbow  Joint.  The  joint  had  not  yet  become  involved, 
there  was  but  little  limitation  of  motion  in  the  elbow  and 
scarcely  any  pain.  The  child  was  a  patient  of  Dr.  Chas. 
N.  Dowd,  who  very  kindly  sent  the  patient  to  me  to  have 
an  X-ray  picture  taken  to  discover  if  possible  whether  and 
to  what  extent  the  bone  was  involved.  It  is  often  possible 
to  make  a  diagnosis  of  early  tuberculosis  in  the  epiphyses 
of  the  long  bones  before  the  associated  joint  disturbances 
are  at  all  marked. 


TUBERCULOSIS   OF   JOINTS  159 

Diagnosis  of  Bone  Tuberculosis. — After  perforation  of  the  overlying  sofl 
parts  and  the  formation  <>i'  ;i  cold  abscess  or  a  sinus,  diagnosis  is  usually  quite 
easy.  In  the  absence  of  such  signs,  the  presence  of  a  tender  bony  swellii 
a  chronic  character,  especially  it'  Dear  a  joint,  will  Lead  to  a  suspicion  of  tuber- 
culosis. The  presence  of  other  tubercular  lesion-  in  the  Lungs,  Lymph  nodes, 
or  elsewhere  renders  the  diagnosis  more  probable.  Absence  of  a  syphilitic  his- 
tory, or,  in  doubtful  eases,  rebelliousness  to  antisyphilitic  treatmenl  is  some- 
times a  further  aid.  The  acute  infectious  processes  of  hone  run  n  far  more 
stormy  course.  The  chronic  suppurations  of  bone  have  certain  distinctive  fea- 
tures noted  under  the  head  of  Acute  and  Chronic  Suppurative  Osteomyelitis 
and  Periostitis.  Further,  tuberculosis  of  the  hones  of  certain  regions  pro- 
duces deformities  and  other  signs  of  a  very  definite  type;  a  description  of 
these  will  be  found  in  the  chapters  on  Regional  Surgery. 

In  certain  cases  an  X-ray  picture  may  show  the  presence  of  tuberculous 
foci  in  bone  with  great  clearness,  and  thus  furnish  valuable  diagnostic  infor- 
mation.     (See  chapter,  "The  X-rays  in  Surgical    Diagnosis.") 

Tuberculosis  of  the  Long  Bones. — Tn  reference  to  tuberculosis  of  the 
long  bones,  it  is  to  be  remembered  that  the  epiphyses  of  long  bones  are  the 
favorite  sea/.  Bony  enlargements  and  inflammations  of  the  shafts  of  long 
bones — especially  in  adults — are  more  apt  to  be  due  to  syphilis,  to  a  new 
growth,  or  to  ordinary  septic  processes. 

TUBERCULOSIS    OF    JOINTS 

Joint  tuberculosis  is  most  frequent  in  childhood  and  youth,  but  may  occur 
at  any  age.  The  knee,  the  hip,  the  ankle,  the  elbow,  the  wrist,  and  the  inter- 
vertebral joints  are  most  commonly  invaded.  One  joint  is  usually  involved, 
occasionally  several  joints  in  succession.  The  disease  is  in  the  larger  number 
of  cases  secondary  to  bone  tuberculosis  of  the  neighboring  epiphyseal  extrem- 
ities. Less  often  the  synovial  membrane  of  the  joint  is  the  primary  seat  of 
the  disease.  The  other  joint  structures  rarely;  the  cartilage,  apparently  never. 
We  may  in  some  instances,  at  least,  distinguish  clinically  between  the  cases 
primary  in  the  bone  and  those  beginning  in  the  synovial  membrane. 

Tubercular  Arthritis — Secondary  to  Bone  Tuberculosis. — The  advent  of  the 
joint  trouble  is  slow  and  insidious;  and  the  subsequent  course,  as  a  rule, 
exceedingly  chronic,  extending  over  months  and  years.  Attention  is  often 
first  called  to  the  affected  joint  by  a  feeling  of  fatigue,  slighl  pain  or  weakness 
in  the  limb  after  prolonged  use.  The  child  is  seen  to  favor  the  part  After 
a  time  a  careful  examination  may  reveal  a  little  tenderness  over  the  point 
in  the  bone  near  the  joint  the  scat  of  the  tuberculous  focus.  At  this  time  the 
joint  will  be  found,  as  a  rule,  normal  in  contour  and  size;  limitation  oi 
motion,  if  present  at  all,  will  be  slight,  and  only  appreciable  upon  careful 
manipulation.  Slight  tenderness  may  be  complained  of  upon  crowding  the 
joint  surfaces  together. 


160 


SURGICAL   TUBERCULOSIS   AND   DISEASES    OF   JOINTS 


In  many  cases  the  symptoms  will  be  so  slightly  marked  that  medical  aid 
will  not  he  sought  for  weeks  or  months.  The  disease  often  shows  at  first 
distinct  remissions,  so  that  the  slight  weakness  or  lameness  will  cease  for  a 
time  to  be  observed.  After  a  time  the  symptoms  return,  and  are  a  little  more 
severe.  It  is  noted  that  the  child  sleeps  badly,  is  restless,  and  utters  sudden 
cries  at  night.  If  carefully  observed,  it  will  be  noted  that  these  cries  are 
associated  with  spasmodic  contractions  of  the  affected  limb.  Lameness  or 
weakness  becomes  distinctly  noticeable;  the  limb  assumes  some  characteristic 
position,  and  attempts  to  make  free  passive  movements  are  resisted  and  attended 
by  pain. 

Typical  Case  of  Tuberculosis  of  the  Knee-joint. — According  to  the  anatom- 
ical seat  of  the  affection  the  signs  will,  of  course,  vary.      If,  for  example, 

the  knee  were  the  seat  of 
the  disease,  examination 
would  show  complete  or 
partial  obliteration  of  the 
normal  depressions  upon 
either  side  of  the  ligamen- 
tum  patella?;  and  slight 
increase  in  circumference 
above  that  of  the  normal 
knee ;  and  a  little  thick- 
ening of  the  periarticular 
soft  parts.  A  tender  point 
is  often  to  be  noted  over 
one  of  the  condyles  of  the 
femur  or  tibia.  The  joint 
is  held  a  little  flexed,  and 
distinct  limitation  of  pas- 
sive and  active  motion  is 
present.  Attempts  to  ex- 
ceed these  limits  are  ac- 
companied by  spasmodic 
fixation  of  the  joint  by 
the  muscles  and  by  pain. 
The  skin  over  the  joint  is 
normal  in  color,  but  may 
feel  a  little  warmer  than 
its  fellow. 
Signs  of  Effusion  into  the  Knee-joint. — There  is  often  at  this  time 
a  moderate  effusion  into  the  joint,  and  the  sensation  known  as  "  floating 
patella "  may  be  appreciated,  although  such  considerable  effusion  is  the 
exception  rather  than  the  rule.  This  sign  is  elicited  in  the  following 
manner : 


Fig.  28. — Tubercular  Arthritis  of  the  Knee  Joint  Show- 
ing Swelling  of  the  Joint  of  the  Characteristic  Spin- 
dle Shape.  Primary  focus  in  the  internal  condyle  of  the 
femur.  Note  the  position  of  moderate  flexion.  (New  York 
Hospital,  service  of  Dr.  P.  R.  Bolton.) 


TUBERCULOSIS    OF   JOIN  I  -  Itil 

The  Unit  is  placed  in  the  extended  position  with  the  heel  supported — if 
the  knee-joinl  i-  flexed  do  amounl  of  fluid  in  the  joint  is  sufficient  to  raise 
the  patella  away  from  tin-  condyles  of  the  femur — tin-  surgeon  places  the 
thumbs  and  middle  fingers  of  each  hand  upon  either  side  of  the  ligamentum 
patella?  and  the  quadriceps  tendon,  one  hand  above  the  other  below  the  patella, 
and  makes  firm  Bteady  pressure  over  these  places,  in  order  to  force  the  fluid 
in  the  joint  beneath  the  patella  and  cause  it  to  lift  this  bone  away  from  the 
condyles  of  the  femur.  The  forefingers  of  either  hand  are  then  placed  upon 
the  patella  and  used  to  push  the  patella  backward  against  the  condyles.  If 
any  considerable  amount  <>f  fluid  exists  in  the  joint  a  feeling  of  elastic  resist- 
ance is  imparted  to  the  fingers.  If  the  pressure  by  the  forefingers  is  suddenly 
increased,  the  resistance  is  overcome,  and  the  patella  is  felt  to  strike  the  con- 
dyles  of  the  femur  a  sharp  tap.  Although  hard  to  describe,  the  manipulation 
is  simple,  and  the  sensation  conveyed  to  the  fingers  ><>  characteristic  as  to 
be  unmistakable.  As  the  pressure  of  the  fingers  is  relaxed,  the  patella  is  felt 
to  rise  again  from  the  condyles. 

The  synovial  bursa  above  the  patella,  and  behind  the  quadriceps  tendon, 
usually  forms  a  part  of  the  knee-joint,  and  may,  if  ir  contains  fluid,  form  a 
rounded  clastic  swelling-  of  considerable  size  beneath  the  quadriceps  tendon. 
The  normal  depressions  on  either  side  of  the  tendon  are  obliterated.  These 
are  some  of  the  signs  of  effusion  into  the  knee-joint,  and  are  observed  when- 
ever fluid  is  present  in  that  joint. 

Later  Symptoms. — Even  early  in  tubercular  arthritis  a  blow  upon  the 
heel  upward,  with  the  knee  extended,  causes  pain.  As  the  disease  goes  on 
all  the  signs  become  more  marked;  the  limb  becomes  more  flexed,  morion — 
active  and  passive — more  restricted;  the  joint  more  swollen,  the  swelling  is 
of  rounded  bullions  character.  The  muscles  of  the  thigh  and  leg  undergo 
partial  atrophy,  and  thus  increase  in  size  of  the  joint  is  more  noticeable.  The 
skin  of  the  knee  is  of  a  dead  white  or  waxy  color  (tumor  albus — white  swell- 
ing). Palpation  of  the  joint  shows  the  periarticular  infiltration  to  be  of  a 
firm  character,  or  in  some  instances  softer  and  almost  boggy.  Bony  foci, 
which  have  reached  the  bone  surface  outside  the  joint,  cause  periosteal  thick- 
ening and  apparent   enlargement  of  one  or  other  bony  condyle. 

From  time  to  time  a  sudden  increase  of  all  the  symptoms  takes  place. 
There  is  acute  pain  in  the  joint,  an  increase  of  swelling,  sometimes  moderate 
fever.  It  may  be  noted  here  that  the  pain  of  joint  tuberculosis  is  not  entirely 
referred  to  the  affected  joint,  but  is  often  in  part  a  referred  pain.  The  most 
common  example  of  this  is  to  be  noted  in  tuberculosis  of  the  hip;  here  the 
pain,  in  the  early  stages  of  the  disease,  is  referred  to  the  inner  aspect  of  the 
knee.  These  sudden  exacerbations  are  sometimes  caused  by  the  invasion  by 
the  tubercular  process  of  hitherto  unaffected  portions  of  the  joint  The  move- 
ments of  the  joint  become  move  and  more  restricted.  In  some  instances  passive 
movements  elicit  crepitation,  indicating  the  rubbing  of  bony  articular  surfaces 
together,  denuded  of  their  cartilages.     Firm,  fibrous,  or,  in  some  cases,  after 

12 


162         SURGICAL   TUBERCULOSIS   AND   DISEASES    OE   JOINTS 


years,  bony  ankylosis  may  result.  The  muscles  become  permanently  shortened. 
In  the  case  of  the  knee,  flexion,  and,  later,  external  rotation  become  more  and 
more  marked.  The  tibia  is  dragged  farther  and  farther  backward  from  the  con- 
dyles of  the  femur,  and  in 
untreated  cases  partial  or 
complete  dislocation  results. 
Cold  Abscess.  —  "When 
the  tubercle  tissue  in  the 
joint  or  in  the  periarticu- 
lar structures  softens  and 
breaks  down  a  tubercular 
abscess  results,  and,  follow- 
ing the  direction  of  least 
resistance,  finally  points 
over,  near,  or,  in  many  in- 
stances, far  away  from  the 
affected  joint.  Rupture  of 
these  abscesses  leaves  be- 
hind the  characteristic  tu- 
berculous ulcer  and  sinus. 
In  old  cases  many  such 
abscesses  may  successively 
form,  one  or  other  may 
wholly  or  partly  heal,  leav- 
ing a  depressed  and  puck- 
ered sear  surrounded  by 
dense  hard  scar  tissue. 

Mixed    Infection. — Sec- 
ondary   invasion    of    these 
tubercular     abscesses     and 
sinuses  with  pus-producing 
organisms  may  change  the 
entire    picture    to    one    of 
acute    or    chronic    septice- 
mia.    As  the  result  of  bony  destruction,  gravity  and  muscular  action,  a  series 
of  typical  deformities  follow  tubercular  arthritis.     Diagnostic  features  of  tuber- 
culosis of  special  joints  will  be  described  under  Regional  Surgery. 

Synovial  Tuberculosis. — Primary  synovial  tuberculosis  is  rare  among  chil- 
dren, and  much  less  common  among  adults  than  the  form  just  described. 
While  the  results  in  some  cases  are  the  same,  the  picture  of  the  disease  varies 
somewhat  from  that  of  the  former  variety.  The  knee  is  the  joint  most  often 
affected,  and  the  disease  is  characterized  in  typical  cases  by  a  sudden  or  grad- 
ual distention  of  the  joint  with  fluid.  Such  fluid  may  be  serous,  sero-fibrinous, 
or  purulent. 


Fig.  29. — Tubercular  Cold  Abscess  of  the  Back  Second- 
ary to  Tuberculosis  of  a  Rib.  (New  York  Hospital 
collection.) 


I  [JBERCULOSIS    OF   JOINTS 


163 


Serous  Fobw  <>r  Synovial  Ttjubebculosis.  The  erout  form  (Hydrops 
tuberculosis)  is  characterized  by  a  eery  chronic  course,  by  absence  of  acute 
inflammatory  signs.  There  is  little  or  no  tendency  to  periarticular  infiltration 
or  thickening;  there  is  eery  little  pain;  no  limitation  of  motion.  The  disten 
tion  of  the  synovial  sac  causes  stretching  of  the  ligaments  and  a  weak  and 
wabbling  joint.'  Genu  valgum,  genu  recurvation,  or  subluxation  may  occur  in 
neglected  cases ;  the  use  of 
the  limli  then  becomes  dif- 
ficult   and    painful.      The 

effusion     may    suddenly    or 

slowly  diminish,  and  even 
disappear,  to  recur  after  a 
\  ariable  interval ;  under 
such  circumstances  there 
may  be  iinicli  difficulty  in 
arriving  a1  a  correcl  diag- 
nosis.       The     existence     of 

other  tuberculous  lesions,  a 
feeble  state  of  health,  and 
flabby  tissues  will  render 
the  diagnosis  of  tuberculo- 
sis more  prohahle.  Aspira- 
tion of  the  fluid  contained 
in  the  joint  and  the  inocu- 
lation of  guinea  pigs  may 
give  a  positive  result.  An 
exception  to  this  picture 
occurs  when,  as  sometimes 
happens,  an  acute  miliary 
tuberculosis    of    the     entire 

synovial  membrane  of  one 
or  more  joints — most  often 
of  the  knee — occurs  in  an 
individual  already  the  sub- 
ject of  tnherculosis  else- 
where.     The   onset   of  the 

joint  symptoms  is  sudden  and  acute;  the  joint  rapidly  swells;  there  is  acute 
pain  from  the  sudden  distention  of  the  synovial  sac;  the  skin  is  reddened 
and  edematous;  the  patient  has  a  considerable  rise  of  temperature.  After 
a  time  the  acute  symptoms  subside,  and  a  chronic  tuberculosis  of  the  joint 
results.  Sealing  and  cure  is  said  in  some  cases  to  ensue  after  the  subsidence 
of  the  acute  symptoms. 

Fibrinous    Fobm    of    Synovial    Tubebculosis    {Hydrops    tuberculosis 
fibrinosum). — The    fibrinous    form    is   characterized    by    the    presence   in    the 


FlO.  30. — Primary  SYNOVIAL  TUBERCULOSIS  "i  mi  K  \i  i 
Joint.  Enormous  Tuberculous  Hydrops.  No  pain.  No 
limitation  of  motion.  Patient  :i  male,  aged  fifty-two  years. 
(New  York  Hospital,  service  <>f  the  author.) 


164 


SURGICAL   TUBERCULOSIS   AND   DISEASES    OF   JOINTS 


serous  exudate  of  considerable  quantities  of  fibrin.  The  presence  of  fibrin 
may  sometimes  be  appreciated  in  the  joint  by  palpation,  a  peculiar  sense  of 
soft  friction  being  transmitted  to  the  fingers.  In  many  instances  these 
cases  of  tuberculosis  hydrops  go  on  to  develop  the  ordinary  form  of  fungous 
arthritis. 

Purulent  Form  of  Synovial  Tuberculosis  {Cold  Abscess  of  the 
Joints). — The  purulent  form  usually  occurs  in  adults,  rarely  in  children. 
The  subjects  are  badly  nourished  and  suffer  from  other  foci  of  tuberculosis. 
The  clinical  signs  and  symptoms  do  not  differ  materially  from  the  serous  type, 
except  that  the  joint  capsule  is  more  apt  to  be  perforated  with  the  production 
of  periarticular  cold  abscess.  The  effusion  may  occur  suddenly  or  slowly,  but 
without  marked  signs  of  an  inflammatory  character.  Aspiration  will  reveal 
the  presence  of  tuberculous  pus  in  the  joint.  The  lesion  is  usually  a  diffuse 
synovial  tuberculosis;  although  similar  abscesses  occur  in  the  tubercular  arteri- 
tes secondary  to  tuberculosis  of  bone. 

Diagnosis  of  Bone  and  Joint  Tuberculosis. — The  diagnosis  is  in  many  in- 
stances extremely  easy.  The  presence  of  sinuses,  the  characteristic  deform- 
ities, and  the  general  appearance  of  a  limb  may  suffice  to  enable  us  to  recog- 
nize the  condition  at  the  first  glance.     This  is  not  always  the  case  in  the  early 

stages  of  the  disease,  and  we 
should  not  be  misled  by  a  gen- 
eral appearance  of  good  health 
in  an  individual  the  subject  of 
chronic  joint  trouble.  It  is 
to  be  borne  in  mind  that  in 
bones  and  joints,  as  elsewhere, 
tuberculosis  may  occur  as  a 
purely  local  disease  without 
disturbance  of  general  nutri- 
tion among  individuals  Avho 
appear  strong  and  well  nour- 
ished. Persons  with  multiple 
tuberculous  lesions  of  long 
standing,  notably  when  com- 
plicated by  chronic  suppura- 
tion, become  cachectic,  and 
develop  amyloid  degeneration 
of  the  kidneys  and  liver,  tu- 
berculosis of  the  intestine, 
chronic  diarrhea,  and  other 
conditions  due  in  part  to  tu- 
berculous disease  and  in  part 
^      •       _,  ,  _  _  to    unfavorable    conditions    of 

Fig.  31. —  Iubercular  Abscess  of  1  high  about  to  Rup- 
ture.   (Collection  of  Dr.  Charles  McBumey.)  environment,  and  in  these  the 


TUBERCULOSIS    OF   JOINTS 


].,;, 


diagnosis  is  plain:  these 
are  nol  the  cases  in  which 
we  may  err. 

Differential  Diagnosis  of 
Bone  and  Joint  Disease. — 
Tuberculosis  of  bones  and 
joints  must  be  differenti- 
ated from  certain  other 
conditions  now  to  be  con- 
sidered. 

Syphilis  of  the  shafts 
of  the  Long  bones  is  gener- 
ally a  much  more  painful 
a  tit -ft  ion  than  tuberculosis. 
The  formation  of  a  large 
cold  abscess,  characteristic 
of  tuberculosis,  does  not 
occur  in  syphilis.  The 
syphilitic  process  is  usual- 
ly of  a  productive  charac- 
ter with  the  formation  of 
new  bone  and  notable  en- 
largement  of  the  shaft. 
Upon  operation  tuberculous 
bone  is  usually  soft  and 
friable.  Syphilitic  bone 
is  dense  and  often  very 
hard.  A  microscopic  diag- 
nosis is  often  possible.  In  certain  anatomical  regions  syphilitic  necrosis 
of  bone  is  so   common   and  rims   so   typical   a   course,   while   tuberculosis   is 


Fig.  32. — Extreme  Contracture  of  both  Knee  Joints  from 
(,><  iescext  Tubercular  Arthritis.  (Collection  of  Dr. 
Charles   MeBurney.) 


Fig.   33.— Syphilitic   Productive    Inflammation   of  the   Tibia   with  Great  Thickening  of  the 

Shaft.     (New  York  Hospital  Museum.) 


166 


SUEGICAL    TUBEECULOSIS    AND    DISEASES    OE    JOINTS 


so  rare,  that  confusion  is  hardly  likely  to  arise.  This  is  notably  true  of 
the  bones  supporting  the  nose  and  the  roof  of  the  mouth.  (See  Regional 
Surgery. ) 

Acute  osteomyelitis  is  a  sudden,  violent  infectious  process  running  an 
acute  course,  and  attended  by  marked  acute  local  and  constitutional  symp- 
toms. It  bears  no  likeness  to 
tuberculosis  in  the  chronic  stage ; 
and  in  the  cases  of  osteomyelitis 
which  are  subacute  or  chronic  the 
following  characteristics  are  to  be 
noted:  Tuberculosis  is  located  in 
the  epiphyseal  ends  of  the  long- 
bones — in  their  shafts  rarely;  sup- 
purative osteomyelitis  affects  the 
shafts  usually — rarely  the  epiphy- 
ses. The  sequestra  of  tuberculosis 
are  small,  ragged,  friable  portions, 
usually  of  cancellous  tissue,  often 
lying  in  a  cavity  lined  with  typical 
tuberculous  granulations.  The  se- 
questra of  osteomyelitis  are  often 
in  the  form  of  long,  flat,  usually 
thin,  plates  of  yellow,  hard,  worm- 
eaten  bone.  They  are  usually  sur- 
rounded by  an  abundant  layer  of 
highly  vascular  granulation  tissue 
and  by  an  abundant  involucrum  of 
healthy  bone  of  new  formation. 
In  the  rare  cases  of  suppurative  osteomyelitis  limited  to  small  foci  in  the 
epiphyses  of  the  long  bones,  and  running  from  the  start  a  subacute  or  chronic 
course,  the  distinction  from  tuberculosis  may  be  impossible  without  operative 
inspection,  and  even  microscopic  examination  of  the  diseased  tissues.  (See 
Osteomyelitis.) 

The  differential  diagnosis  between  a  simple  relapsing  or  chronic  articular 
hydrops  of  traumatic  origin  and  a  tubercular  hydrops  is  not  always  possible 
without  prolonged  observation.  Immobilization  of  the  joint  for  a  few  weeks 
is  usually  followed  by  improvement  in  both  conditions.  Each  recurrence  of 
the  effusion  in  the  absence  of  a  trauma  renders  the  diagnosis  of  tuberculosis 
more  probable.  We  are  often  justified  in  opening  and  washing  out  the  joint 
if  the  condition  has  proved  itself  rebellious  to  other  forms  of  treatment,  when 
the  character  of  the  fluid  and  the  appearance  of  the  synovial  membrane  may 
suffice  to  render  the  diagnosis  clear.  (For  tuberculous  lesions  of  other  struc- 
tures, see  Regional  Surgery.) 


Fig.  34. — Syphilitic  Necrosis  -with  Destrttcttox 
of  the  Nasal  Boxes.  Hereditary  syphilis.  (Col- 
lection of  Dr.  Charles  McBurney.) 


DISEASES   OF   JOINTS 


1 07 


DIFFERENTIAL    DIAGNOSIS    OF   TUBERCULOSIS   FROM    CERTAIN 
OTHER    DISEASES    OF    JOINTS 

Arthritis  Deformans. —  Arthritis  deformane  occurs  in  elderly  people  or 
follows  severe  trauma  i.e.,  fractures  into  the  joint,  healing  with  deformity. 
The  progress  of  the  disease  is  slow  bul  steady;  cur.-  with  restitutio  ad  integrum 
is  impossible.  The  remissions  and  exacerbations  of  tuberculosis  are  absent  or 
less  marked.  The  ends  of  the  bones  forming  the  joint  are  enlarged,  often  much 
more  than  ever  occurs  in  tuberculosis,  or  bony  absorption  takes  pine-  at  one 
point  while  hyperostosis  is  present  in  another.  The  deformities  differ  nota- 
bly from  those  of  tubercu- 
losis and  are  characterisl  ic. 
( Sec  Arthril  is  I  deformans  of 
Special  Joints. )  Sometimes 
bony  outgrowths  c;in  ho  felt 
along  the  borders  of  the 
joint  or  loose  bodies  within 
the  synovial  sac.  Abscesses 
and  sinuses  do  not  appear, 
nor  does  caries  or  necrosis 
occur.  Several  joints  are 
commonly  affected. 

Hysterical  Joints. — In 
joints  not  easily  accessible 
to  direct  palpation  the 
mimicry  of  hysteria  may 
for  a  time  render  the  ex- 
clusion  of  serious  organic 
lesions  difficult.  The  follow- 
ing are  some  of  the  diagnos- 
tic characters  to  be  noted 
in  purely  neurotic  joint 
affections:  The  amount  of 
pain  and  tenderness  com- 
plained of  doc-,  nol  corre- 
spond with  the  physical 
signs.  Tenderness  is  su- 
perficial or  general,  or  is 
felt  over  an  area  which 
does  not  correspond  to  the 
anatomical  arrangement  of 
nerve  trunks,  often  geo- 
metrical in  form.  The  muscular  spasm  and  limitation  of  motion  or  fixation 
of  the  joint  disappear  during  narcosis.     The  pain  does  not  usually  interfere 


Fig.  35.     Charcot's  Elbow  i\    \  <'\-i    op  Tabes  Dorsalis. 
Note  the  absence  of  atrophy  of  tin-  limb  so  common! 
in  tuberculosis.     (New  York  Hospital,  service  of  Dr.  I.  A. 
Stimson.) 


168 


SURGICAL    TUBERCULOSIS    AND    DISEASES    OF    JOINTS 


with  sleep.     Vasomotor  disturbances  of  the  affected  region  are  common.     Hy- 
peresthesia of  the  skin  over  the  entire  joint,  subjective  sensations  of  heat  or 

cold  and  tingling  are  often 
present,  and  areas  of  anes- 
thesia are  sometimes  to  be 
noted.  Improvement  or 
cure  often  follows  the  use 
of  painful  or  disagreeable 
methods  of  treatment — for 
example,  the  actual  cau- 
tery, the  wet-pack,  etc. 
(See  "  Traumatic  Hys- 
teria.") 

Charcot's  Joint. — The 
disorganization  of  a  joint 
in  the  course  of  tabes  dor- 
salis  bears  but  slight  re- 
semblance to  tubercular 
arthritis.  There  is  in  most 
of  these  cases  a  history  of 
syphilis.  Other  signs  of 
tabes  are  present — loss  of 
knee-jerk,  the  character- 
istic pains  of  tabes,  trophic 
disturbances  of  the  skin  of 
the  soles  of  the  feet,  the 
Argyll  Robertson  pupil, 
disturbances  of  the  blad- 
der and  rectum,  or  some 
combination  of  these  signs. 
The  knee  is  the  joint  most 
often  affected.  There  is  a 
striking  absence  of  pain 
and  tenderness  in  the 
joint.  There  is  no  limitation  of  passive  motion.  The  ligaments  are 
relaxed,  permitting  an  undue  amount  of  lateral  mobility  of  the  bones. 
The  joint  usually  contains  much  fluid.  There  is  often  destruction  of 
the  cartilages,  complete  or  partial,  and  fibrous  or  bony  grating  on  passive 
motion.  Manipulations  of  this  kind  are  painless,  or  but  slightly  pain- 
ful. In  fact,  the  most  important  diagnostic  sign  of  the  disease  is  the 
absence  of  pain  in  presence  of  the  perfectly  evident  destructive  lesion  of 
the  joint. 

Traumatic  Synovitis  in  Tabes. — A  milder  form  of  joint  disturbance  occurs 
in  many  cases  of  locomotor  ataxia,  notably  in  the  knee-joint;  the  condition 


Fig.  36. — Charcot's  Knee-joint.    (New  York  Hospital,  serv' 
ice  of  Dr.  Frank  Hartley.) 


DISEASES    01    JOINTS 


169 


follows  trauma,  a  blow,  ;i  sprain,  sufeh  ;is  these  patients  are  constantly  I » •  i 1 1 ^ 
subjected  to  "ii  accounl  of  their  imperfectly  coordinated  movements  and  dimin- 
ished sensibility.  The  joinl  (very  often  the  knee)  exhibits  a  moderate  pain- 
less distention  with  Quid,  ;i  serous  synovitis,  which  diminishes  or  disappears 
under  appropriate  treatment,  but  is  prone  i"  recur  and  to  become  chronic. 
The  diagnosis  is  easily  made  from  concomitanl  signs  and  symptoms.  Some 
of  the  severe  forms  of  tabetic  joinl  disturbance  run  an  acute  course.  The 
knee  may  be  entirely  disorganized  in  ;i  few  weeks.  Portions  of  the  condyles 
of  tli<'  femur  or  tibia  may  be  found  loose  in  the  joinl  cavity,  and  spontaneous 
fractures  of  the  shaft  of  the  femur  or  tibia  may  occur.  While  the  picture 
does  qo1  bear  any  resemblance  to  tuberculosis,  there  is  n  certain  likeness  to 
arthritis  deformans,  excepl  thai  the  productive  character  of  the  hitter  i-  want- 
ing, do  new  bone  is  thrown  out,  no  cartilaginous  plates  are  to  be  felt,  and  no 
ankylosis  occurs. 

Pyogenic  infection   is  nol  very  uncommon  in  the  course  of  tabetic  joints. 
The   process  runs  a   violent   course  under  the  guise  of  a    rapidly  destructive 


Fig.  :>7. — Arthritis  Deformans  of  the  Joints  of  thi    Fingers  in    w  Oi«d  Woman.     (New  York 

Hospital  Medical  Service.) 


septic  arthritis.  The  tissues  react  feebly  or  nol  at  all.  The  joinl  becomes 
distended  with  pus;  the  joinl  capsule  is  soon  perforated,  and  periarticular 
purulent  infiltration  and  abscess  run  riot  up  and  down  the  limb.  The  symp- 
toms of  profound  septicemia  coexist.  The  articular  ends  of  the  bones  and 
the  ligaments  mell  away,  and  total  destruction  of  the  joinl  is  sometimes  accom- 
plished in  a  surprisingly  short  time. 


170 


SURGICAL   TUBERCULOSIS   AXD   DISEASES    OF   JOINTS 


Intermittent  Hydrops  of  Joints. — A  rare  and  obscure  affection  which  exhib- 
its the  characters  of  an  acute  serous  synovitis,  most  often  of  one  or  both  knee- 
joints,  occurs  without  apparent  cause;  conies  on  suddenly,  lasts  usually  for 
three  or  four  days,  and  as  suddenly  disappears  or  diminishes,  only  to  recur 
after  an  interval  which  appears  to  be  fairly  constant  for  the  given  case.  Ac- 
cording to  Benda,  who  collected  fifty-six  cases,  the  intervals  between  the  attacks 
are  most  commonly  eleven  or  thirteen  days,  sometimes  nine  days,  sometimes 
four  weeks.  Swelling  of  the  thigh  and  of  the  face  sometimes  accompanies  the 
effusion  into  the  joint. 

I  have  recently  observed  one  case.  The  patient  was  a  man,  aged  twenty- 
seven  years.  His  first  attack  had  occurred  five  years  before.  Without  ap- 
parent cause  a  sudden  effu- 
sion took  place  in  the  right 
knee-joint.  There  was  pain 
in  the  knee  and  swelling, 
but  no  tenderness  or  red- 
ness of  the  skin.  The  joint 
had  become  normal  at  the 
end  of  a  week.  Since  that 
time  he  had  had  eleven 
attacks,  sometimes  in  the 
right,  sometimes  in  the  left 
knee.  The  attacks  have 
gradually  diminished  in 
frequency.  They  have  not 
been  influenced  by  any 
form  of  treatment, 
have  they  exhibited 
definite  periodicity, 
observed  attack  was  quite 
typical ;  the  left  knee  was 
greatly  distended  with 
fluid,  and  painful.  There 
were  no  signs  of  periar- 
ticular infiltration.  There 
was  fever— 102°  F.— but 
no  constitutional  depres- 
sion. Pulse  not  affected. 
The  effusion  disappeared 
in  four  days  entirely.  A 
new  effusion  then  appeared 
in  the  opposite  knee,  persisted  a  few  days,  and  disappeared.  The  joints  then 
appeared  to  be  normal,  and  the  patient  withdrew  himself  from  observation, 


nor 
any 
The 


Fig. 


38.  —  Arthritis   Deformans   of  the   Knees. 
(Collection  of  Dr.  Charles  McBurney.) 


DISEASES    OF    JO] 


171 


Syphilis  <»i    Joints 

Syphilitic  Arthralgia. — During  the  early  months  of  acquired  syphilis,  pain 
of  a  severe  character,  and  worse  al  night,  i-  commonly  felt  in  the  joints.  Such 
pains  are  also  a  trery  fre- 
quenl  symptom  in  hered- 
itary syphilis.  In  the  ac- 
quired form  such  pains 
more  commonly  precede 
the  general  eruption  than 
fellow  it.  The  symptoms 
arc  subject ive  merely.  Ob- 
jectively, no  signs  of  joint 
disturbance  are  to  be  ob- 
served. The  diagnosis  is 
t<>  be  made  by  the  other 
evidences  of  syphilitic  in- 
fection— by  the  disappear- 
ance of  the  pains  as  the 
patient  comes  under  the 
influence  of  mercury. 

Syphilitic      Synovitis. — - 

Syphilitic  inflammation  of 
the  joints  occurs  during 
the  early  or  active  period 
of  the  disease  as  a  mono- 
or  polyarticular  serous 
synovitis.  Its  appearance 
may  be  synchronous  with 
that  of  the  general  cutane- 
ous eruption,  or  occur  at 
any  time  during  the  active 

period  of  the  disease.  The  joints  arc  painful,  swollen:  local  heat  may  be 
present  or  not;  the  skin  is  rarely  reddened.  The  joints  may  be  moved,  within 
certain  limits,  without  increase  of  pain;  beyond  such  limits  motion  is  painful. 
If  several  joints  are  involved  the  process  ends  in  complete  resolution  in  all 
after  a  week  or  two,  or  one  joint  may  recover  more  slowly  or  become  the  sear 
of  a  chronic  synovitis.  During  the  acute  portion  of  the  attack  there  is  a  little 
fever.  The  presence  of  other  signs  of  active  syphilis  will  usually  serve  to 
exclude  acute  articular  rheumatism.  As  in  all  syphilitic  lesions,  the  effect 
of  treatment    is  an   important   aid   in  diagnosis. 

Syphilitic  Arthritis. — During  the  Inter  or  tertiary  stage  of  syphilis,  and  in 
hereditary  syphilis,  a  variety  of  joint  disturbances  may  occur,  due  to  primary 
gummatous  infiltration  of  the  joint  structures  themselves  or  to  secondary  in- 


l'i<;.    39. — Arthritis    Deformans    of    the    Joints  of  the 
Toes.     (New  York  Hospital,  Out-Patient   Department.) 


172         SURGICAL   TUBEECULOSIS    AND    DISEASES    OF    JOINTS 

volveinent  of  the  joint  from  gummata  of  the  hones.  The  knee  and  sterno- 
clavicular joints  are  most  often  affected.  The  elbow,  wrist,  ankle,  metatarsal, 
metacarpal,  and  interphalangeal  joints  are  involved  in  the  above  order  of 
frequency  (Hartley).  The  lesions  are,  briefly,  fibrous  degeneration  of  the  car- 
tilages, papillary  thickening  of  synovial  membrane,  gummata  in  any  of  the 
periarticular  structures.  The  fluid  in  the  joint  is  serous,  or,  in  the  event  of 
gummata  breaking  down  into  the  joint  cavity,  puriform  or  purulent.  Perios- 
titis and  enlargement  of  the  epiphyses,  not  unlike  that  observed  in  rachitis  and 
due  to  periostitis  or  osteomyelitis  of  the  epiphyses,  is  a  common  lesion  in  the 
hereditary  syphilis  of  children.  The  disease  is  rarely  acute,  usually  chronic 
in  its  course.  The  clinical  picture  closely  resembles  tubercular  arthritis ;  the 
bulbous  enlargement  of  the  joint  is  the  same,  but  the  periarticular  thickening 
is  more  dense  and  firm  in  syphilis.  The  formation  of  abscess  and  joint  sup- 
puration is  very  rare  in  syphilis.  The  pain  of  syphilis  is  often  severe,  and 
worse  at  night.  Functional  disability  is  far  less  marked  in  syphilis^  and 
scarcely  corresponds  with  the  gravity  of  the  organic  lesion.  The  acute  exacer- 
bations of  tuberculosis,  with  an  accompanying  fever,  are  wanting  in  syphilis. 
The  contractures  of  the  muscles  and  the  resulting  deformities  are  similar  in 
the  two  diseases.  The  limitation  of  motion  is  less  marked  in  syphilis  than  in 
tuberculosis,  although  both  may  be  followed  by  complete  or  partial  ankylosis. 
Other  evidences  of  syphilis  may  be  present — a  history  of  infection,  osteitis, 
and  periostitis  of  the  long  bones.  Syphilitic  scars  or  ulcers  should  be  sought 
for.  Gummata  are  not  infrequently  present,  and  may  be  palpable  as  firm, 
insensitive  nodules  around  the  affected  joint,  in  the  soft  parts,  or  on  the  bones. 

Bilateral  Disturbance  of  the  Knee-joints. — In  hereditary  syphilis,  bilateral 
disturbance  of  the  knee-joint  is  fairly  frequent.  The  occurrence  of  a  sudden 
effusion  into  both  knees  in  a  young  child,  without  much  constitutional  dis- 
turbance, is  cause  for  suspicion  of  this  disease. 

"  The  following  varieties  of  joint  disturbance  may  be  distinguished  in 
hereditary  syphilis  (Robinson)  :  1.  A  specific  epiphysitis,  with  or  without 
spontaneous  separation  of  the  epiphysis.  2.  Symmetrical  effusions,  occurring 
suddenly  and  without  pain,  commonly  between  the  eighth  and  fifteenth  year 
of  life.  3.  Osteitis,  (a)  with  simple  effusion,  (b)  with  gummatous  infiltration 
of  the  synovial  membrane  and  effusion.  4.  Primary  gummatous  synovitis. 
(See  Diseases  of  Special  Joints.) 

"  Interstitial  keratitis  is  a  frequent  complication.  Suppuration  of  joints 
is  much  more  common  in  the  hereditary  than  in  the  acquired  form  of  the 
disease."      (P.  Keichel.) 

Hemarthros  in  Hemophilia. — In  persons — notably  children — the  subjects  of 
hemophilia,  sudden  effusions  of  blood  into  one  or  several  joints  occasionally 
occur,  without  apparent  cause  or  after  slight  trauma.  The  knee-joint  is  the 
most  frequent  seat.  The  effusion  occurs  suddenly,  and  without  pain.  The 
joint  is  found  to  be  distended  with  fluid.     The  occurrence,  after  a  time,  of 


DISEA8E8    01    JOINTS  173 

ecchymotie  discoloration  of  the  -kin,  it  no  injury  has  occnrred,  and  a  family 
or  persona]  history  of  bleeding,  may  lead  to  a  correct  diagnosis,  [f  seen  at 
a  later  3tage,  a  differentia]  diagnosis  from  tuberculosis,  gout,  or  rheumatism 
may  be  very  difficult  The  blood  may  be  entirely  absorbed  with  perfecl  restora- 
tion <>f  function,  or  the  clot  may  be  replaced  by  organized  tissue  and  ;i  greater 
or  less  degree  of  Limitation  of  motion  may  remain,  or  even  ankylosis  and 
contracture  of  the  muscles,  with  a  high"  grade  of  deformity.  Absence  of  ab- 
Bcess  or  fistula?,  the  occurrence  of  effusions  in  several  joint-  in  succession,  with 
absorption  after  a  time  ami  return  to  a  norma]  Btate,  and  a  notable  anemia, 
constitute  some  of  the  diagnostic  data  of  this  rather  rare  condition. 

Gonorrheal  Rheumatism. —  Metastatic  inflammations  of  joints  occur  in  from 
two  t<»  three  per  cenl  of  the  cases  of  gonorrhea.  The  condition  i-  sometimes 
due  t<»  constitutiona]  invasion  and  localization  in  the  Bynovia]  membranes  of 
joints,  tendons,  and  bursas  by  the  gonococcus  alone,  sometime-  apparently  to 
mixed  infection,  with  pyogenic  bacteria  in  addition.  In  the  joint  exudate  the 
gonococcus  has  heen  demonstrated  morphologically  in  a  number  of  cases,  usually 
during  the  early  days  of  the  jdlnl  inflammation.  The  disease  i<  more  common 
in  men  than  in  women.  Tt  occurs  most  commonly  during  the  three  months 
following  infection,  but  rarely  before  the  end  of  the  first  week.  The  <li~<a-.- 
affects  the  knee  mosl  often,  then  the  ankle,  the  fingers  and  toes,  wrist,  shoulder, 
etc.  Several  joints  may  lie  involved  successively,  ami  one  attack  predis]  -  - 
to  another.  More  than  half  the  cases  are  polyarticnlar.  The  disease  occurs 
in  mild  and  severe  forms,  according  to  the  intensity  of  the  infection.  The 
exudate  may  he  serous,  sero-fibrinous,  sero-purulent,  or  in  rare  cases  purulent. 
Open  the  onset  of  the  joint  symptoms  the  urethral  discharge,  if  such  existed, 
usually  diminishes  or  ceases.  Tn  men,  the  disease  occurring  as  it  does  in  the 
course  of  gonorrhea  is  easily  recognized;  in  women  it  is  not  always  so.  At  t lie 
onset  of  the  acute  form  of  the  disease  there  is  often  malaise,  moderate  fever — 
99.5  '  to  102°  F.- — pain  in  one  or  several  joints,  and,  finally,  pain  and  swelling 
in  one  joint,  usually  the  knee.  The  intensity  of  the  symptoms,  local  and  gen- 
eral, vary  with  the  severity  of  the  infection.  Tn  the  milder  serous  and  sero- 
fibrinous forms  the  knee  will  be  swollen,  tender,  more  or  less  painful,  red.  and 
hot,  and  the  signs  of  fluid  in  the  joint  will  be  distinct.  These  symptoms  last 
for  a  few  days  or  a  fortnight;  in  favorable  cases  they  entirely  disappear  in 
three  or  four  weeks.  Relapses  are  common,  and  may  lead  to  a  chronic  syno- 
vitis, a  synovitis  with  papillary  thickening  of  the  synovial  membrane,  to  in- 
tractable fibrous  ankylosis,  or  even  to  bony  ankylosis,  or  a  condition  resembling 
arthritis  deformans.  The  patella  is  very  apt  in  these  chronic  cases  to  become 
adherent  to  the  condyles  of  the  femur.  Tn  the  purulent  and  sero-purulent  cases 
the  symptoms  will  be  more  severe.  The  pain,  heat,  redness,  and  swelling  oi 
the  joint  will  be  more  marked;  there  will  he  more  edema  and  infiltration  of  the 
periarticular  structures;  there  may  he  severe  throbbing  pain  in  the  joint; 
rarely,  actual  suppuration  takes  place,  the  capsule  of  the  joint  is  perforated, 
periarticular  abscesses   form.     Some  of  these  cases  develop  pyemia;  the  most 


174         SUEGICAL   TUBERCULOSIS   AND   DISEASES    OF   JOINTS 

favorable  outcome  is  ankylosis.  In  men,  the  presence  of  a  urethral  discharge 
or  of  a  posterior  urethritis,  with  shreds  or  purulent  urine,  will  suggest  the  true 
cause  of  the  joint  affection.  In  women,  the  signs  of  recent  gonorrheal  infection 
are  not  always  plain.  In  cases  of  doubt,  the  urethra,  the  Bartholinian  ducts, 
and  the  cervix  uteri  should  be  examined  for  a  gonococcus-bearing  discharge. 

Diagnosis  of  Acute  Exudative  Lesions  of  Joints. — -As  the  result  of  subcutane- 
ous and  open  wounds,  as  complications  in  the  course  of  a  great  number  of 
general  diseases,  most  of  them  of  an  infectious  character,  and  in  the  regular 
course  of  special  diseases  of  the  joints  themselves,  an  exudative  inflammation 
takes  place  in  the  joint  structures,  and  the  synovial  cavity  becomes  more  or 
less  distended  with  fluid.  Such  fluid  may  consist  of  serum,  of  serum  and  fibrin, 
of  serum  containing  a  moderate  amount  of  pus,  or,  finally,  of  pus.  We  speak 
of  a  serous  synovitis  or  arthritis,  a  sero-fibrinous  synovitis  or  arthritis,  a  sero- 
purulent  synovitis  (the  catarrhal  synovitis  of  von  Volkmann),  or  a  purulent 
arthritis,  if  the  exudate  consists  of  true  pus. 

Use  of  the  Aspirating  Needle. — In  accessible  joints,  when  in  doubt  as 
to  the  character  of  the  fluid,  we  may  introduce  an  aspirating  needle  into  the 
joint  cavity,  under  proper  precautions,  and  withdraw  some  of  the  fluid  for 
examination.  It  may  be  well  to  remark  in  passing,  that  clotted  blood,  cannot 
be  made  to  pass  through  a  needle,  and  that  partly  clotted  blood  passes  with 
difficulty.  The  exudate  of  serous  synovitis  is  a  pale,  straw-colored  fluid,  usually 
slightly  turbid  from  small  flocculi  of  fibrin.  Under  the  microscope,  moderate 
numbers  of  leucocytes  may  be  seen  singly  or  in  groups,  with  a  greater  or  less 
number  of  red  blood  cells,  if  the  synovitis  was  of  traumatic  origin.  A  sero- 
fibrinous exudate  contains  masses  and  flocculi  of  fibrin  in  varying  amounts. 
The  sero-purulent  exudate  is  distinctly  cloudy,  and  under  the  microscope  is  seen 
to  consist  to  considerable  extent  of  white  cells.  The  purulent  exudates  exhibit 
the  ordinary  characters  of  pus. 

Synovites. — Causation. — Subcutaneous  injuries  of  joints — contusions,  dis- 
tortions, and  the  like — are  followed  by  a  serous  synovitis.  Open  wounds  of 
joints,  if  noninfected,  may  be  followed  by  a  similar  process.  Mono-  and  poly- 
articular acute  rheumatism  and  gout  are  accompanied  by  a  synovitis  of  this 
type.  Serous  synovites  are  not  uncommon  in  the  course  of  active  syphilis.  The 
acute  infectious  diseases — measles,  scarlet  fever,  small-pox,  gonorrhea,  diph- 
theria, erysipelas,  typhoid  fever — are  often  complicated  by  synovites,  sometimes 
serous,  sometimes  sero-purulent  or  purulent  in  character.  Acute  suppurative 
processes  in  the  neighborhood  of  joints  may  extend  to  and  infect  the  joints 
themselves — acute  osteomyelitis  and  periostitis,  for  example,  as  well  as  infected 
wounds  and  abscesses  of  the  soft  parts  overlying  the  joint.  Metastatic  sup- 
puration in  joints  is  common  in  pyemia  (see  Pyemia).  The  diagnosis  of  some 
of  these  forms  of  joint  inflammation  merit  separate  attention,  and  will  be 
found  under  appropriate  headings.  Some  of  the  characters  of  the  different 
types  of  inflammation  may,  however,  be  spoken  of  here. 

The  acute  serous  synovites  following  injury  are  easy  to  recognize.     The 


DISEASES   OF   JOINTS  17;, 

injury  is  usually  rather  severe:  ;i  violent  wrench  of  the  joint,  Buch  thai  one 
or  more  ligaments  are  stretched  or  torn,  a  severe  contusion,  n  partial  or  com- 
plete  dislocation,  or  a  fracture  In  the  neighborhood  of  the  joint  is  the  usual 
cause.  The  effusion  occurs  al  once,  or  within  a  few  hours.  The  join!  becomes 
swollen,  .-iinl  in  suitable  situations  fluctuation  in  the  joint  is  appreciable.  Pain 
may  be  slight,  moderate,  or  severe,  according  to  the  degree  of  tension  of  the 
capsule  caused  l>\  the  effusion.  The  joinl  will  feel  weak,  limitation  of  motion 
will  he  more  or  less  marked,  and  passive  motion,  carried  beyond  n  certain  de- 
gree,  will  he  more  or  less  painful.  The  skin  will  usually  he  normal  in  color, 
and  there  will  he  little,  if  any,  local  heat.  Fever  is  absent,  or  quite  moderate — 
99.5  to  km  F.  Under  rest  and  fixation,  the  effusion,  etc.,  will  begin  to  sub- 
side in  a  few  days.  The  formation  of  a  hematoma  in  a  joint  cavity  (hemar- 
thros)  may  he  suspected  if  the  effusion  fails  to  diminish  rapidly  after  a  few 
days  of  rest,  and  if,  without  evidence  of  fracture  or  external  contusion,  eechy- 
niotie  spots  make  their  appearance  near  the  joint.  Further,  the  sofl  friction 
of  fibrinous  masses  may  sometimes  be  felt  on  manipulation.  The  introduction 
of  an  aspirating  needle  will  answer  the  question  positively.  In  the  presence  of 
an  open  wound  of  a  joint  the  escape  from  the  wound  of  a  clear,  yellowish 
or  blood-stained,  sticky  fluid  is  sufficient  evidence  that  the  joint  is  wounded, 
and  a  change  in  the  character  of  this  fluid  to  sero-purulent  or  purulent  dis- 
charge indicates  that  the  joint  cavity  is  infected.  In  accidental  wounds  of 
joints  it  is  of  the  greatest  consequence  to  recognize  such  infection  at  the  earliest 
possible  moment.  The  constitutional  symptoms  of  sepsis  may  come  on  suddenly 
and  violently  before  the  local  evidences  of  joint  infection  are  marked:  but,  on 
the  other  hand,  the  process  is  very  often  insidious,  and  constitutional  symptoms 
may  be  slight  for  many  days,  while  the  joint  structures  are  becoming  too  pro- 
foundly affected  to  save  by  conservative  local  treatment. 

Pyogenic  Infection  of  Joints. — Coiksk  of  tiik  Disease. — The  ordinary 
course  of  purulent  wound  infection  of  the  larger  joints  is  as  follows:  The 
joint  becomes  intensely  painful;  there  is  fever,  often  with  a  sudden  marked 
rise  of  temperature;  in  some  instances  a  chill.  The  joint  rapidly  swells,  the 
skin  over  the  joint  is  edematous,  often  hot  and  red;  the  whole  limb  is  often 
swollen.  The  function  of  the  joint  is  abolished  and  the  slightest  movement 
causes  exquisite  suffering.  The  exudate  in  the  joint  may  or  may  not  give 
rise  to  fluctuation:  it  is  frequently  small  in  amount  at  first,  and  may  be  masked 
by  the  swelling.  The  joint  is  held  in  such  a  position  as  to  relax,  as  far  as 
may  be,  the  tension  of  its  capsule,  usually  in  a  position  of  partial  flexion.  The 
further  course  depends  upon  the  character  of  the  infection,  and  to  a  great 
extent  upon  the  treatment.  Cultures  made  from  the  purulent  exudate  often 
furnish  useful  data  upon  which  to  form  an  opinion  of  the  gravity  of  the  situa- 
tion. The  presence  of  the  yellow  staphylococcus  or  of  Streptococcus  pyogenes 
indicates  a  grave  form  of  infection.  In  bad  cases  the  symptoms  become  those 
of  septicemia  or  pyemia.  All  the  joint  structures  become  involved  in  the 
suppurative  process  (  panarthritis).     The  cartilages  are  softened  and  separated 


176         SURGICAL    TUBERCULOSIS   AND   DISEASES    OF   JOINTS 

from  the  bones,  the  ligaments  are  softened  and  relaxed,  the  joint  capsule  is 
perforated,  and  abscesses  form  outside  the  joint  and  burrow  up  and  down  the 
limb  in  the  intermuscular  planes.  Subluxation  may  occur.  Healing,  with 
limitation  of  motion  or  ankylosis,  are  the  most  favorable  results  to  be  expected 
in  these  cases.      (See  Regional  Surgery.) 

Metastatic  Synovites. — The  metastatic  synovites  complicating  the  acute  in- 
fectious diseases  are  sometimes  confined  to  one  joint ;  more  often  they  are 
polyarticular.  They  are  frequently  purulent  in  character,  and  are  in  many 
instances  part  of  a  secondary  pyemia.  Sometimes  the  exudate  is  serous  or 
sero-purulent,  and  the  course  of  the  disease  more  like  that  of  an  acute  poly- 
articular rheumatism.  Even  in  the  purulent  forms  the  local  signs  are  much 
less  acute  than  is  the  case  when  a  joint  becomes  infected  through  an  open  wound. 
They  may  be  but  slightly  painful  (see  Pyemia).  In  all  acute  synovites,  if  we 
except  rheumatism  and  gout,  the  development  of  fever  and  other  constitutional 
symptoms  leads  to  the  suspicion  that  the  joint  inflammation  is  of  a  sero-puru- 
lent or  purulent  character. 

Catarrhal  Synovitis. — The  so-called  catarrhal  form  of  synovitis  occurs  as  a 
sero-purulent  joint  inflammation  in  children.  The  disease  is  accompanied  by 
moderate  constitutional  disturbance.  Fever  is  present,  but  is  not  high.  The 
local  signs  are  those  of  an  acute  synovitis  with  pain,  swelling,  and  limitation 
of  motion  and  function ;  but  the  process  does  not  usually  end  in  true  suppura- 
tion, nor  are  the  inflamed  joints  destroyed.  Recovery  is  possible  even  without 
operation.  The  cause  of  the  condition  is  obscure  in  a  certain  proportion  of 
cases. 

Gout. — Gout  occurs  as  an  acute  synovitis,  notably  in  the  metatarso-phalan- 
geal  joint  of  the  great  toe  and  in  the  finger-joints.  It  is  a  disease  of  middle  and 
later  life ;  is  associated  with  an  excess  of  uric  acid  in  the  blood.  Is  character- 
ized by  a  tendency  to  recurrent  attacks,  and  by  the  deposit  in  the  periarticular 
soft  parts  of  crystals  of  urates,  sometimes  forming  considerable  masses  pro- 
ducing notable  deformities  and  disturbance  of  function  in  the  affected  joints; 
such  gouty  tophi,  as  they  are  called,  may  attain  a  considerable  size.  An  acute 
attack  of  gout  comes  on  quite  suddenly,  with  great  pain  in  the  affected  toe-joint. 
The  joint  swells;  the  skin  is  reddened  and  exquisitely  tender;  motion  is  very 
painful.  The  attack  subsides,  with  or  without  treatment,  after  two  to  four  to 
eight  days  or  more.  The  situation — absence  of  trauma,  often  a  history  of 
alcoholic  indulgence,  and  of  recurrences — together  with  the  local  signs,  are 
sufficient  to  establish  the  diagnosis.  Gouty  tophi  often  form  in  the  border  of 
the  external  ear  as  well  as  in  the  vicinity  of  joints. 

Ankylosis. — When,  as  the  result  of  injury  or  disease,  a  joint  becomes  stiff 
and  immovable,  the  condition  is  known  as  ankylosis.  When  the  immobility  is 
absolute  and  dependent  upon  changes  in  the  articular  surfaces,  we  speak  of  a 
true  ankylosis.  When  the  immobility  is  largely  due  to  muscular  contraction 
such  as  is  common  in  inflammations  of  joints  and  in  cases  of  hysteria,  and  is 
completely  or  partly  overcome  under  anesthesia,  we  speak  of  a  false  ankylosis. 


Dl SKA si'ls    OF   JOINTS  177 

When,  along  with  more  or  less  complete  immobility,  the  joinl  is  flexed  at  an 
angle  and  rigidly  1 1<  - 1  <  I  by  permanently  shortened  muscles,  we  speak  "I  the 
condition  as  a  contracture.  Contractures,  ankyloses,  and  subluxations  are  often 
found  together  in  diseased  joints.  While  in  mosl  instances  the  present 
ankylosis  is  readily  appreciated  by  testing  the  mobility  of  the  joint,  it  is 
usually  desirable  to  know  the  cause  and  character  of  the  Limitation  of  motion 
for  therapeutic  and  prognostic  reasons.  Aside  from  the  history  of  the  case, 
we  may  call  to  our  aid  inspection  and  palpation  of  the  part,  with  and  without 
genera]  anesthesia,  and  the  use  oi   the  X  rays. 

Etiology  of  Ankylosis.— Some  of  the  causes  «>f  limitation  of  motion  in 
the  joints  are  the  following: 

Injuries  and  diseases  of  Ihc  soft  parts  in  the  neighborhood  <>j  the  joint 
other  limn  the  joint  structures  themselves,  such  as  produce  cicatricial  con- 
traction of  the  skin,  fasciae,  muscles,  tendons,  tendon  sheaths.  Prolonged 
fixation  of  a  joinl  in  a  flexed  position,  whether  by  design  or  neglect,  in 
the  treatment  of  fractures  and  other  conditions;  limitation  of  motion  in 
these  cases  is  rarely  absolute;  the  joinl  can  usually  be  moved  to  some  extent, 
often  freely  in  one  direction  while  motion  is  limited  or  impossible  in  another. 
The  history  of:  the  ease  usually  aids  greatly  in  the  diagnosis.  The  presence 
of  extensive  sears  following  burns  or  other  injuries  with  loss  of  substance  is 
a  self-evident  causative  factor.  I ntlaniniat ions  of  the  muscle-,  tendons,  and 
tendon  sheaths,  whether  suppurative,  tubercular,  or  other,  often  leave  -cars; 
the  fixation  of  the  tendons  and  muscles  can  usually  be  recognized  on  attempt- 
ing to  move  the  limb.  Under  anesthesia  the  immobility  persist-  to  a  greater 
or  less  extent,  \)\\\  the  elements  of  pain  and  muscular  spasm  are  eliminated, 
and  the  actual  degree  of  ankylosis  is  easier  to  appreciate. 

Ankyloses  due  /<>  injury  and  disease  of  the  joint  structures  themselves. 
Fractures  through  a  joint,  with  displacement  or  with  the  formation  of  new 
hone,  may  mechanically  interfere  with  the  movements  of  the  joinl  ;  such  anky- 
loses are  very  easy  to  recognize.  After  healing  of  the  fracture  the  movements 
of  the  joint  are  sharply  limited  in  certain  directions.  The  mechanical  obsta- 
cles to  motion  are  best  learned  by  a  series  of  X-ray  pictures  of  the  joinl  :  by 
this  means  they  can,  as  a  rule,  be  very  accurately  determined.  A  moderate 
degree  of  limitation  of  motion  usually  follows  dislocations  after  reduction. 
The  synovial  membrane  forms  adhesions  to  itself  or  to  the  bone,  such  thai  for 
some  weeks  motion  in  the  joint  is  limited  and  attempts  at  further  motion  are 
painful.  With  use,  the  limitation  of  motion  slowly  passes  away.  If  the 
patient  is  timid,  it  is  sometimes  necessary  to  make  passive  motions  "t  the 
joint  under  anesthesia   and   break   up   the  adhesions. 

Acute  or  chronic  inflammations  of  the  ]<>'nils  of  all  kinds  may  be  followed 
by  cicatricial  contraction  of  the  synovial  membrane,  the  joint  capsule,  and 
Ligaments,  such  that  the  normal  movements  of  the  joint  are  no  longer  possible. 
The  history  of  the  disease,  the  presence  of  limited  motion,  and  a  normal  X-ray 
picture  of  the  bones  renders  the  diagnosis  simple.  It  is  to  be  borne  in  mind 
13 


178         SUKGICAL   TUBERCULOSIS   AND   DISEASES    OF   JOINTS 

that  fibrous  or  cartilaginous  union  between  joint  surface  is  readily  distin- 
guished from  bony  union  by  a  good  X-ray  picture.  In  cases  of  fibrous  or  car- 
tilaginous union,  the  bones  appear  separated  by  a  distinct  interval.  If  care 
be  taken  to  place  the  tube  in  proper  relation  to  the  limb,  or,  better  still,  by 
taking  stereoscopic  pictures,  when  bony  union  is  present  the  continuity  of  bony 
structure  is  perfectly  evident  upon  inspecting  the  X-ray  negatives.  The  longer 
the  inflammatory  process  has  existed  and  the  more  severe  its  character  the 
more  the  likelihood  that  firm  ankylosis  will  occur.  Such  ankylosis  may  be 
at  first  fibrous,  later  cartilaginous,  and  finally  bony.  In  bony  ankylosis,  passive 
efforts  to  bend  the  joint  do  not  cause  muscular  spasm  of  the  limb.  In  other 
forms,  pain  or  the  fear  of  pain  causes  the  muscles  of  the  limb  to  contract 
powerfully. 

It  is  well  to  remember  that  violent  efforts  to  break  up  a  fibrous  ankylosis 
caused  by  an  antecedent  inflammation  of  the  joint  structures  has  often  pro- 
duced a  violent  reaction,  and  no  improvement  in  the  condition  of  the  joint. 
This  is  especially  true  of  cases  of  ankylosis  following  suppurative,  tubercular, 
and  gonorrheal  inflammation  of  joints.  It  is  also  quite  possible  to  produce 
a  fracture  in  such  cases,  notably  when  the  bones  are  atrophied  from  disuse 
of  the  limb.  The  deformities  of  the  articular  ends  of  bones  accompanying 
arthritis  deformans,  trophic  lesions  of  joints  (tabetic  arthritis,  syringomyelia), 
and  some  tuberculous  lesions — such  that  the  bones,  by  the  formation  of  bony 
outgrowths  or  by  bony  absorption,  no  longer  fit,  and  therefore  are  incapable  of 
gliding  smoothly  over  one  another — can  be  appreciated  by  palpation  and  manip- 
ulation of  the  joint  and  by  X-ray  pictures.  The  history  of  these  cases  usually 
renders  the  diagnosis  simple.  In  certain  joints — notably  the  hip-  and  the 
shoulder- joint — it  is  necessary,  when  testing  the  degree  of  mobility  in  the  joint, 
to  bear  in  mind  the  mobility  of  the  lumbar  spine  and  of  the  scapula,  respect- 
ively. (See  Regional  Surgery.  For  the  diagnosis  of  the  congenital  deformities 
and  acquired  contractures  of  special  joints,  see  Regional  Surgery.) 


CHAPTEE    V 

DISEASES   OF    BoNKS 
ACUTE    OSTEOMYELITIS 

Acute  suppurative  inflammation  of  the  medulla  and  periosteum  of  the 
bones  occurs  as  the  resull  of  infection  with  one  or  other  of  the  forms  of  pus- 
producing  bacteria j  most  often  the  Staphylococcus  pyogenes  aureus,  sometimes 
other  forms  of  pyogenic  staphylococci,  and  occasionally  Streptococcus  pyogenes. 
Mixed  infections  are  also  ohserved.  The  disease  may  originate  without  appar- 
ent cause.      In  many  cases  infection  takes  place  through  the  1»1 1  from  some 

small  suppurative  lesion  of  the  skin,  an  acne  pustule,  a  furuncle,  or  a  small 
infected  wound.  The  nineous  membrane  of  the  mouth  and  throat,  and  notably 
the  tonsils,  are  no1  infrequent  portals  of  entry.  Local  trauma,  often  of  slight 
degree,  seems,  by  producing  a  place  of  diminished  resistance,  to  determine 
the  locale  of  the  hone  infection.  Fatigue  and  exposure  to  cold  and  wet  appear 
sometimes  to  act  as  exciting  causes.  Osteomyelitis  is  often  secondary  to  the 
acute  exanthemata,  To  diphtheria,  and  to  typhoid  fever.  The  disease  occurs 
most  frequently  in  males  (4-  to  1)  between  the  ages  of  eight  and  seventeen 
years.  It  is  less  common  among  infants,  and  is  rare  as  a  primary  dis  - 
after  the  hones  have  attained  their  growth. 

Osteomyelitis,  as  the  result  of  direct  infection  of  compound  fractures  and 
of  wounds  laving  hare  the  bones,  may  occur  at  any  age.  In  the  spontaneous 
form  of  the  disease  the  shafts  of  the  long  bones  are  most  often  involved.  Ac- 
cording to  statistics  of  440  cases  compiled  by  Haage  from  v.  Bruns's  clinic,  the 
disease  affected  the  femur  in  38.5  per  cent;  the  tibia,  42.16  per  cent ;  the  fibula, 
•">.iU  per  cent;  the  humerus,  11  per  cent;  radius,  .">.l  per  cent;  ulna.  3.4  per 
cent.  One  or  several  hones  may  be  involved  simultaneously  or  successively. 
The  ends  of  the  -hafts  of  the  long  hones  arc  the  sites  of  predilection  for  the 
beginning  of  the  process.  The  disease  may  run  an  acute  or  chronic  course. 
In  the  mosl  severe  cases  of  the  acute  variety  the  clinical  picture  is  that  of 
a  profound  septic  intoxication,  and  death  may  occur  in  a  few  days  before  the 
local  signs  are  at  all  marked.  The  disease  may  he  ushered  in  by  a  chill,  with  a 
rapid  rise  of  temperature  to  lit  I  or  more,  and  a  corresponding  acceleration 
of  pulse  rate.  Prostration  i-  profound,  and  cerebral  symptoms,  head- 
ache,  delirium,   stupor,    and   coma   occur  and   succeed   one   another   so    rapidly 

17'.' 


180  DISEASES    OF   BONES 

that  the  characteristic  local  symptoms  may  entirely  escape  notice.  There  is 
often  a  septic  diarrhea.  The  diagnosis  in  these  most  violent  cases  is  often 
not  made  nor  even  suspected  during  life. 

Local  Symptoms — In  the  ordinary  acute  cases  the  local  signs  and  symptoms 
are  well  marked  and  characteristic.     They  will  be  considered  separately. 

Pain. — One  of  the  prominent  symptoms  of  the  disease  is  pain  of  an 
intense  and  excruciating  character  referred  to  the  affected  limb.  The  pain 
may  be  most  intense  over  the  focus  in  the  bone  or  referred  to  the  entire  bone 
or  to  a  neighboring  joint — for  example,  in  osteomyelitis  of  the  femur  the 
pain  is  often  most  intense  in  the  knee.  The  pain  is  worse  at  night  and  when 
the  fever  is  highest.  It  is  described  as  tearing,  boring,  or  throbbing  in  char- 
acter, and  is  of  horrible  severity.  When  the  pus  within  the  medullary  cavity 
has  perforated  the  cortical  layer  and  spread  itself  beneath  the  periosteum  or 
in  the  soft  parts  of  the  limb  the  pain  subsides  or  disappears.  When  a  new 
focus  of  infection  occurs  in  a  distant  bone  a  new  area  of  pain  is  felt,  and  fur- 
nishes a  reliable  indication  of  the  presence  of  pus. 

Tenderness. — Tenderness  along  surface  of  the  infected  bone  is  present  as 
soon  as  the  overlying  periosteum  becomes  irritated  and  inflamed,  and  appears 
early  in  the  disease.  The  whole  length  of  the  bone  or  only  a  portion  of  it 
may  be  tender,  but  the  greatest  tenderness  will  be  noted  over  the  inflammatory 
focus,  and  this  symptom  affords  a  valuable  guide  for  operative  interference. 
( Senn. ) 

Swelling. — During  the  first  few  days  the  bone  may  be  but  little  swollen; 
later,  usually  at  the  end  of  a  week,  secondary  periostitis  causes  a  dense,  hard 
swelling  of  the  bone.  Thrombosis  of  the  deeper  veins  is  regularly  present, 
and  edema  of  the  limb  results  with  marked  and  extensive  swelling,  often  involv- 
ing the  entire  limb.  When  the  soft  parts  become  involved  in  the  suppurative 
process  a  brawny  infiltration  is  added  with  burrowing  of  pus  along  the  bone 
and  the  intermuscular  planes.  The  origin  of  trouble  in  the  interior  of  the 
bone  may  thus  be  lost  sight  of. 

Dilatation  of  Veins. — The  superficial  veins  of  the  limb  are  notably 
dilated,  and  constitute,  after  the  first  few  days,  a  diagnostic  sign  of  impor- 
tance. 

Redness. — Not  until  burrowing  pus  is  near  the  surface  does  the  skin 
become  red,  and  such  redness  is  purple,  blue,  or  dusky-reddish  brown,  and 
circumscribed.  Earlier  the  skin  has  a  pale  or  normal  color,  and  is  often 
shiny  from  swelling  and  tension. 

Loss  of  Function. — Loss  of  function  in  a  limb  the  seat  of  acute  osteo- 
myelitis is  absolute ;  the  patient  is  entirely  unable  to  move  or  use  it  in  any  way ; 
this  symptom  is  invariable'  and  characteristic. 

Spontaneous  Fracture. — If  the  entire  circumference  of  the  shaft  of  the 
bone  becomes  separated  as  a  sequestrum  before  sufficient  new  bone  has  been 
formed  around  it  to  afford  strength  to  the  limb  a  fracture  may  occur  from 
slight  degrees  of  violence,  or  even  from  moving  the  limb  during  a  dressing. 


\(  I   II     081  EOMYELITIS  |s| 

rrin's  accident  it  doI  common.  It  doe-  Dot  occur  until  the  disease  baa  Lasted  a 
long  time,  and  is  therefore  of  qo  early  diagnostic  importance. 

Sepabatioh  op  the  Epiphysis, — [f  the  epiphyseal  cartilage  becomes 
Involved  in  the  suppurative  process,  ii  is  disintegrated,  and  the  epiphysis  and 
shafl  of  the  bone  become  detached,  simulating  a  fracture;  Buch  separation 
is  of  prognostic  importance.  The  epiphyseal  cartilage  being  destroyed,  the 
Bubsequenl  growth  of  the  bone  may  be  seriously  interfered  with,  and  the  limb 
may  remain  shorter  than  its  fellow,  if  further  growth  of  the  norma]  limb 
occurs.  In  s^mc  cases  the  lesion  is  near,  bul  does  uol  involve  the  cartilage; 
this  sometimes  results  in  an  irritative  overgrowth  <>l'  the  affected  bone,  which 
grows  larger  than  its  fellow.     (See  Osteomyelitis  <>f  the  Tibia.) 

Synovitis. — An  effusion  into  the  neighboring  joinl  is  a  regular  accom- 
paniment of  osteomyelitis.  It  occurs  as  a  serous  inflammation  as  the  result 
of  circulatory  disturbances,  and  is  to  he  recognized  by  the  signs  elsewhere 
described.  In  a  certain  proportion  of  cases  as  a  result  of  extension  of  the 
purulent  infection.  Purulent  synovitis  of  a  septic  character  arises  as  a  serious 
complication,  and  is  to  be  recognized  by  the  local  signs  referable  to  the  joint 
(see  Joints)  and  by  an  increased  gravity  in  the  general  symptoms  of  sep- 
ticemia. 

General  Symptoms. — The  constitutional  symptoms  of  acute  osteomyelitis 
are  those  of  septic  intoxication  or  acute  or  chronic  septicemia  or  pyemia, 
according  to  the  extent  and  intensity  of  the  infection  and  the  practicability 
and  promptness  of  intelligent  surgical  treatment.  As  noted,  the  gravest  forms 
of  the  disease  are  characterized  by  the  sudden  onset  of  an  overwhelming  septic 
intoxication.  The  less  violent  forms  exhibit  every  gradation  of  septic  fever. 
The  temperature  is  of  the  continuous  remittent  type,  usually  higher  in  the 
evening.  The  remissions  are  less  marked  than  is  the  rule  in  typhoid  fever. 
The  occurrence  of  a  new  focus  of  infection  is  accompanied  by  an  increased 
elevation  of  the  temperature  curve.  The  pulse  is  increased  in  rapidity  through- 
out, and  is  perhaps  a  better  index  of  the  gravity  of  the  case  than  is  the  body 
temperature.  In  the  severe  cases  the  tongue  is  dry  and  coated:  the  lips  and 
teeth  coated  with  sordes.  Confusion  with  meningitis  may  arise  when  the  early 
occurrence  of  cerebral  symptoms,  a  typhoid  state,  muttering  delirium  ami 
stupor,  absence  of  local  si-^ns  of  suppuration  during  the  early  days  of  the 
disease,  fail  to  attract  the  attention  of  the  surgeon  to  the  bony  lesion, 

Leuco<  ytosis. —  Leucocytosis,  with  a  relative  increase  in  polymorpho-nu- 
clear  leucocytes,  is  a  regular  accompaniment  of  osteomyelitis,  and  may  give 
the  clew  to  the  diagnosis  in  doubtful  cases. 

The  following  history  illustrates  the  course  of  a  case  of  acute  osteomyelitis 
of  the  tibia  ending  fatally  on  the  fifth  day  after  the  onset  of  acute  symptoms: 

A  boy,  aged  seven  years,  received  ;i  blow  with  a  stick  over  the  upper  part  of 
the  left  shin  hone  twelve  days  before  coming  under  observation.  A  trifling  amount 
of  pain  and  soreness   followed  the  injury,  hut   soon   passed  away.     Ten  days  after 


182  DISEASES    OF   BONES 

the  injury,  he  began  to  suffer  severe  pain  in  the  left  leg.  The  onset  of  the  pain  was 
followed  by  a  chill,  vomiting,  prostration,  and  fever.  He  came  under  observation 
two  days  later.  At  this  time  he  looked  very  ill.  His  face  was  flushed;  his  tongue 
dry  and  covered  with  a  brown  coating;  his  lips  dry  and  fissured.  He  was  restless 
and  at  times  delirious.  There  was  slight  general  rigidity  of  the  muscles.  Heart, 
lungs,  and  abdomen  negative.  Temperature,  104.2°  P.;  respiration,  28;  pulse,  132. 
The  left  leg  was  much  swollen,  notably  in  the  upper  third.  The  skin  was  white, 
shiny,  and  felt  hot  to  the  touch.  There  was  great  tenderness  over  the  upper  third 
of  the  tibia.  No  evidence  of  fluid  in  knee-joint,  passive  movements  of  joint  painful 
but  not  restricted.  The  superficial  veins  of  the  leg  were  visibly  dilated.  Hemo- 
globin, seventy  per  cent.  Leucocytosis  of  29,800.  Polynuclear  cells,  relative  in- 
crease ninety  per  cent.  Operation  the  following  da}^.  Incision  over  upper  third 
of  tibia.  Medullary  cavity  opened  with  mallet  and  gouge.  Considerable  pus  evacu- 
ated, medulla  extensively  involved  in  suppurative  process.  Curettage  and  disinfec- 
tion. Needle  introduced  into  knee-joint  withdrew  clear  fluid.  Cultures  from 
medulla  of  tibia  and  from  fluid  in  knee  developed  pure  cultures  of  Staj)hylococcus 
pyogenes  aureus.  No  improvement  in  the  septic  symptoms  followed  the  operation. 
The  temperature  continued  elevated.  The  pulse  gradually  increased  in  frequency 
and  became  weaker  and  more  compressible.  Delirium  became  constant  and  was 
followed  by  stupor.  Involuntary  evacuation  of  urine  and  feces.  Leucocytosis  on 
day  after  operation,  39,000.  Death  forty-eight  hours  after  operation.  Ante-mortem 
rise  of  temperature  to  106.2°  F. 

Differential  Diagnosis. — The  diseases  with  which  osteomyelitis  is  often  con- 
founded are:  Typhoid  fever,  acute  articular  rheumatism,  meningitis,  phleg- 
monous inflammation  of  the  soft  parts,  periostitis. 

Typhoid  Fever. — The  presence  of  inflammatory  leucocytosis  usually  of 
marked  character  in  osteomyelitis,  and  its  absence  in  typhoid,  constitute  an 
important  means  of  differentiation.  Careful  search  for  tender  points  or  local- 
ized enlargements  of  bone  should  be  made.  The  regular  occurrence  of  diar- 
rhea and  abdominal  pain  and  tenderness  in  the  early  days  of  typhoid  are  less 
common  in  osteomyelitis,  although  some  cases  of  osteomyelitis  are  preceded 
by  diarrhea  and  bronchitis.  Widal's  reaction,  although  valuable  in  the  sec- 
ond week  of  typhoid,  cannot  be  relied  upon  in  the  early  days  of  the  disease  as 
a  means  of  excluding  suppurative  processes.  The  onset  of  typhoid  fever  is 
rarely  so  sudden  as  is  the  case  in  osteomyelitis,  the  regular  prodromata  of  the 
disease  are  rarely  entirely  absent,  and  repeated  chilly  sensations  are  the  rule 
rather  than  the  sudden  violent  chill  which  commonly  ushers  in  osteomyelitis. 

Acute  Articular  Rheumatism.  —  Acute  rheumatism  usually  affects 
more  than  one  joint.  The  pain  and  swelling  are  limited  to  the  vicinity  of 
the  inflamed  joints  and  are  not  diffuse  as  in  osteomyelitis.  Moreover,  joint  com- 
plications do  not  occur  in  osteomyelitis  until  the  disease  has  lasted  for  some 
days,  usually  for  ten  days,  two  weeks,  or  more.  The  general  symptoms  are 
much  more  severe  in  bad  cases  of  osteomyelitis  than  in  rheumatism. 

Phlegmonous  Inflammation — Phlegmonous  Erysipelas. — While  ordi- 
nary erysipelas  bears  no  resemblance  to  osteomyelitis,  since  the  characteristic 


SUBACUTE    OSTEOMYELITIS  L83 

dermatitis  of  erysipelas  is  always  easy  to  recognize,  and  hae  verj  definite  charac- 
teristics of  its  own,  it  might  well  happen  thai  in  the  presenct  of  extensive  bur- 
rowing suppuration  in  the  soft  parts  after  the  bone  abscese  hae  perforated  the 
cortex,  ilif  bone  lesion  mighl  be  overshadowed  and  escape  notice,  [ncisiona 
for  drainage  and  relict'  of  tension  would,  if  an  atrium  be  discovered  in  the  bone, 
render  the  origin  of  the  trouble  clear.  If  no  atrium  is  found,  the  periosteum 
will  be  thickened,  velvety,  and  easily  stripped  from  the  bone;  blood-stained 
pus  will  usually  be  found  beneath  the  periosteum;  the  cortical  layer  will  appear 

dead    while   or  yellow.       In    any   ease   of   doubt,    a    small    opening    may    be    made 

through   the  corticalis   with   a  gouge  or   trephine   and   the   medullary   cavity 

exposed. 

SUBACUTE    OSTEOMYELITIS 

While  among  children  spontaneous  osteomyelitis  of  the  Bhafts  of  the  l"HLr 

hones  usually  runs  a  very  acute  course,  cases  occur  among  adults  of  a  3UD- 
acute  character  from  the  start,  although  the  lesions  may  be  very  extensive  and 
multiple.  The  following  history  of  a  ease  in  my  service  at  the  New  York  Eos- 
pita]  will  serve  to  illustrate  this  rather  uncommon  type  of  the  disease: 

M.  P.,  married,  aged  forty  years,  had  a  miscarriage  a1  two  months,  twenty-sis 

davs  before  admission,  followed  by  general  malaise  and  general  pains.  Twelve  davs 
ago  a  sharp  chill,  \'r\v\\  prostration,  and  pain  in  the  right  upper  arm.  several  days 
later  moderate  swelling  of  the  limb.  The  general  and  local  symptoms  haw  grown 
worse  up  to  the  present  time.  On  admission,  patient  rather  poorly  nourished  and 
pale.  Temperature,  103.2°  F.;  respiration,  32;  pulse,  128.  Leucocytosis,  87,500. 
Polymorphonuclear  cells,  eighty-five  per  cent.  Lymphocytes,  fifteen  percent.  Eb 
thirty-seven  per  cent.  Right  arm  swollen,  but  not  very  painful.  Marked  tender- 
ness over  upper  third  of  right  humerus.  This  portion  of  the  bone  feels  thicker 
than  normal;  indistinct  fluctuation  felt  beneath  the  deltoid.  Operation  August 
tlth.  Incision  opened  an  abscess  beneath  the  deltoid  containing  several  ounces  of 
evil-smelling,  greenish  pus.  Periosteum  of  humerus  raised  from  upper  third  of 
hone  by  a  purulent  collection  surrounding  the  shaft;  further  exploration  Bhowed 
the  periosteum  everywhere  thickened,  velvety,  and  loosened.  The  entire  shaft 
appears  white  and  pale  yellowish-green.  With  a  gouge  and  mallet  the  medullary 
cavity  was  opened  from  end  to  end  and  found  tilled  with  stinking,  ^w^'n  pus. 
Continued  fever  of  a  remittent  type,  seldom  higher  than  102°  F.,  followed  the  opera- 
tion. The  wound  remained  fairly  clean  and  the  bone  was  gradually  partly  covered 
by  granulations.  September  9th,  a  chill.  Temperature  rose  a  little  higher  during 
the  following  days.  The  leucocyte  count  which  had  fallen  after  the  operation  rose 
again.  Pain  was  complained  of  in  the  left  humerus  and  right  femur,  but  was  not 
very  severe.  Power  third  of  femur  and  upper  third  of  humerus  became  tender 
and  felt  thickened.  Operation.  September  15th.  Diffuse  purulent  osteomyelitis  of 
both  femur  and  humerus,  similar  to  that  found  at  the  first  operation  and  a  similar 
Operation.  Cultures  of  the  pus  from  the  right  humerus  had  been  aegative.  Cul- 
tures from  the  femur  showed  a  spore-bearing  rod-shaped  bacillus,  not  identified. 
Gradual  improvemenl  in  general  condition  followed.    The  extensive  wounds  granu- 


184 


DISEASES    OF   BONES 


lated.  The  patient  went  home  on  October  28th  at  her  own  request,  with  bare  bone 
at  the  bottom  of  all  the  granulating  wounds.  She  finally  recovered  completely 
without  necrosis  of  bone. 


THE    SUBSEQUENT    HISTORY 

The  subsequent  history  of  those  cases  of  osteomyelitis  which  survive, 
whether  operated  on  or  not,  varies.  In  the  most  favorable  cases  early  operation 
may  be  followed  by  rapid  subsidence  of  the  septic  symptoms.  The  periosteum 
reapplies  itself  to  the  bone,  and  the  wound  slowly  fills  in  and  heals.  Usually 
the  vitality  of  some  portion  of  the  shaft  is  not  restored.     The  periosteum  fails  to 

cover  it  entirely.  The  dead  bone  is 
slowly  separated  from  the  living  by 
the  formation  of  granulation  tissue 
at  the  line  of  junction.  Such  a 
sequestrum  may  be  a  small  super- 
ficial scale,  or  may  consist  of  the 
entire  thickness  of  the  shaft  for  a 
variable  length  up  to  the  entire 
diaphysis.  The  periosteum  forms 
a  new  layer  of  bone  more  or  less 
completely  surrounding  the  seques- 
trum. This  involucrum  of  new 
bone  is  penetrated  here  and  there 
by  cloaca?,  through  which  pus  is 
discharged  in  greater  or  less  quan- 
tity as  long  as  the  sequestrum  is 
present.  The  time  necessary  for 
the  separation  of  the  dead  fragment 
varies  from  weeks  to  many  months. 
Under  unfavorable  general  and  lo- 
cal conditions  these  patients  may 
die  of  chronic  sepsis  with  amyloid 
degeneration  of  the  liver,  spleen, 
kidneys,  etc.  As  long  as  the  pa- 
tient's general  condition  remains 
fairly  good,  it  is  customary  to  wait 
for  the  separation  of  the  sequestrum 
before  removing  it  by  operation. 
The  recognition  of  the  presence  of  dead  bone  is  usually  very  simple. 
There  will  be  a  typical  history  of  an  acute  attack  of  osteomyelitis,  an  infected 
compound  fracture,  or  some  equally  characteristic  event.  There  will  be  the 
presence  of  one  or  more  sinuses  from  which  pus  is  discharged.  Quite  often 
the  greenish-yellow  or  ivory-white  sequestrum  will  be  visible  at  the  bottom  of 


Fig.  40. — Circumscribed  Chronic  Osteomyelitis 
of  the  Tibia,  Showing  Sinus  Leading  to 
Dead  Bone.     (Service  of  Dr.   F.  W.  Murray.) 


PERIOSTITIS    Al,i;i'.\ll.\(is.\    AND    SCLEROSING    OSTEOMYELITIS     L85 

;m  open  wound,  or  can  readily  be  fell  with  the  finger  or  probe.  The  question 
whether  or  ool  the  sequestrum  is  separated  from  the  living  bone  will  n>»t  always 
be  easy  to  answer.  I n 
Mime  cases  it  may  be 
moved  with  the  finger, 
a  probe,  or  in  the  grasp 
of  an  artery  forceps, 
or  pried  up  a  little 
with  a  periosteum  ele- 
vator; in  other  cases 
ii  may  be  so  deeply 
placed,  or  so  firmly  in- 
closed by  the  involu- 
criini  of  new  bone,  or 

be    of    such     a     shape, 

that  efforts  to  detect  its 

bility  may  fail.     If 

more  than  six  months 
have  elapsed  since  the 
original  attack,  and  it' 
the  sinuses  leading  to 
the  sequestrum  are 
lined  with  healthy 
granulations,  it  may 
generally  be  assumed 
that  it  is  loose.  Some- 
times the  surgeon  will 
have  t<>  he  guided  by 
the  length  of  time 
which  has  elapsed 
since  the  original  in- 
fect inn  occurred,  or 
will,  in  the  presence 
of  genera]  sepl  i<-  symp- 
toms demanding  oper- 
ative relief,  discover  only  during  the  operation  whether  the  sequestrum  has 
separated.     The  X-rays  are  a  valuable  aid. 


Fig.  41.  —X-ray   op  Cask  Shown  i\   Fig.  40,  Showing  Thicken- 
ing   OF   Sua  V  I    OP  THE    BONE    FROM    ChRONK      InFI    UfMATION    AM) 

Cavity  in  iiii:  Shaft  Containing  a  Small  Sequestrum. 


PERIOSTITIS    ALBUMINOSA    AND    SCLEROSING    OSTEOMYELITIS 

Two  rare  forms  oJ  infectious  bone  inflammation  may  lie  mentioned  pos- 
sessing  the  peculiarity  that,  although  caused  by  pyogenic  uerins.  they  do  not 
end  in  suppuration.  They  are  the  so-called  periostitis  albuminosa  and  the 
sclerosing  osteomyelitis  without  the  formation  of  pus. 


186  DISEASES    OF   BONES 

Periostitis  Albuminosa. — This  disease  begins  as  an  acute  process,  with  pain, 
fever,  tenderness,  and  swelling  of  the  extremity,  leads  finally  to  the  formation 
of  a  sequestrum,  but  the  process  may  extend  over  a  period  of  months,  and  the 
subperiosteal  exudate  consists  not  of  pus,  but  of  a  peculiar  albuminous  mucoid 
material.  I  operated  upon  one  such  case  in  the  Roosevelt  Hospital  some  years 
ago.  The  patient  was  a  man ;  the  disease  had  existed  for  two  months  when  he 
came  under  observation.  The  lower  half  of  the  right  tibia  was  notably  enlarged, 
tender,  and  painful ;  there  was  no  fever.  Upon  operation  the  periosteum  was 
much  thickened  and  raised  from  the  bone  over  an  area  six  inches  long  by  a 
cloudy  and  sticky  albuminous  exudate,  nonpurulent.  The  surface  of  the 
shaft  in  front  was  necrotic  for  a  distance  corresponding  to  the  loss  of  continuity 
with  the  periosteum,  but  was  not  separated.  The  dead  bone  was  chiseled  away. 
Recovery  without  further  necrosis  and  without  suppuration  followed.  After 
the  acute  onset  the  inflammation  is  prone  to  subside  into  a  subacute  or  chronic 
process.  The  perforation  of  the  periosteum  overlying  the  inflamed  bone  may 
be  delayed  for  many  weeks. 

Sclerosing  Osteomyelitis. — In  this  form  of  the  disease  the  onset  is  acute, 
and  is  attended  by  the  ordinary  signs  and  symptoms  of  acute  inflammation 
of  bone,  including  periosteal  thickening  and  infiltration  of  the  overlying  soft 
parts.  The  process  does  not,  however,  end  in  suppuration ;  the  acute  symptoms 
subside,  leaving  behind  a  permanent  thickening  of  bone.  In  some  of  these 
cases  continuous  or  recurring  attacks  of  pain  may  be  felt  in  the  sclerotic 
bone  extending  over  a  period  of  years.  The  patient's  general  health  may  be 
seriously  interfered  with  from  continued  suffering.  Upon  operating  on  these 
cases  we  may  find  no  lesion  except  the  thickened,  dense,  ivorylike  bone ;  in 
other  cases  there  may  be  found  in  the  midst  of  the  indurated  bone  a  minute 
abscess  cavity  containing  a  very  small  sequestrum;  such  abscesses  may  remain 
for  many  years,  causing  no  symptoms  except  pain.  It  will  not  always  be 
easy  to  differentiate  these  cases  from  syphilis.  The  diagnosis  will  depend 
upon  a  history  of  an  acute  febrile  attack  and  of  acute  local  symptoms  at  the 
original  onset  of  the  disease,  absence  of  a  syphilitic  history,  and  of  other  signs 
of  syphilis,  want  of  improvement  following  the  use  of  mercury  and  iodid  of 
potash,  the  presence  of,  or  history  of,  acute  osteomyelitis  in  other  bones. 

PERIOSTITIS 

It  is  seldom  that  we  are  able  to  recognize  a  primary  inflammation  of  the 
periosteum  apart  from  inflammation  of  the  overlying  soft  parts,  on  the  one 
hand,  or  involvement  of  the  underlying  bone,  on  the  other.  Syphilis  furnishes 
more  examples  of  a  pure  periostitis  than  other  conditions,  as  elsewhere  described. 
Tuberculous  periostitis  is  probably  nearly  always  a  secondary  process.  Acute 
suppurative  periostitis  occurs  commonly  enough  as  a  complication  of  infected 
wounds  of  the  extremities  and  the  scalp  when  the  periosteum  is  incised  or 
torn;  further,  in  combination  with  infection  of  the  soft  parts  and  bone  sub- 


CIRCUMSCRIBED   0STEOMYELI1  is  [87 

stance  in  compound  fractures,  and  in  infected  amputation  stumps,  and,  ae 
already  described,  in  acute  osteomyelitis,  Infectious  processes  of  the  fingers 
(panaritium  bone-felon)  are  "Men  complicated  by  secondary  involvement  of 
the  periosteum  of  the  phalanges;  the  phalanx  Is  infected,  completely  cul  off 
from  ils  blood  supply,  dies,  and  may  conic  away  or  I"'  extracted  as  a  seques- 
trum. In  nil  these  conditions  the  periostitis  forms  bul  a  pari  of  the  lesion, 
mid  requires  qo  separate  description.  A  common  Bymptom-complex  in  ;ill  cases 
of  periostitis  consists  of  localized  pain  and  tenderness,  periosteal  thickening, 
apparent,  or  later,  real  enlargement  of  the  bone.  In  suppurative  conditions, 
followed  by  the  formation  of  a  subperiosteal  abscess,  often  by  loss  of  bone 
substance;  in  nonsuppurative  conditions,  by  temporary  or  permanenl  bone 
enlargement. 

Periostitis,  the  Result  of  Contusion  of  the  Bone. — The  metacarpal  bones  and 
the  phalanges  of  the  fingers,  the  tibia,  the  os  calcis,  and  less  commonly  other 
superficial  bones,  may  be  the  seat  of  an  acute,  subacute,  or  chronic  inflamma- 
tion of  the  periosteum,  nonsuppurative  in  character,  and  characterized  by 
localized  pain  and  tenderness,  by  palpable  thickening  of  the  periosteum,  and 
disturbance  of  function  of  the  affected  part.  The  condition  is  not  inaptly 
called  by  the  laity  "  stone  bruise."  As  affecting  the  os  calcis  it  i~  common 
among  country  boys  who  go  barefoot.  Among  adults  the  condition  is  notably 
frequent  among  laboring  men  as  the  result  of  contusions  of  the  metacarpal 
hones  and  phalanges  of  the  ringers  from  misdirected  hammer  blows  and  the 
like;  further,  among  those  who  indulge  in  fisticuffs  with  naked  hands. 

Signs  and  Symptoms. — The  signs  and  symptoms  in  these  cases  are  local 
pain  and  tenderness  over  the  affected  hone,  moderate  swelling.  Palpation  in 
the  case  of  the  bones  of  the  hand  usually  reveals  thickening  of  the  affected 
hone  and  some  limitation  of  motion  in  the  neighboring  joint.  The  heat,  red- 
ness, and  great  tenderness  of  a  suppurative  lesion  are  wanting,  the  condition 
tends  to  continue  for  weeks  and  months,  and  gradually  to  subside  under  mas- 
sage, etc.  In  all  these  cases  it  is  very  desirable  to  take  a  pair  of  stereoscopic 
radiographs  of  the  hand,  since  many  of  them  will  he  found  to  he  fractures 
with  impaction  and  very  slight  deformity.  If  near  a  joint  a  small  amount 
of  deformity  or  the  production  of  a  small  amount  of  new  hone  may  permanently 
interfere  with  the  function  of  the  joint.  A  certain  amount  of  pain  is  present 
for  many  months,  and  a  greater  or  less  degree  of  limitation  of  motion  which 
may  be  permanent.  The  actual  lesion  is  often  so  slighl  a.-  entirely  to  escape 
any  method  of  examination  except  a  good    X-ray   picture. 

CIRCUMSCRIBED    OSTEOMYELITIS 

Circumscribed  loci  of  suppuration  occur  in  the  bones,  in  the  epiphyses, 
and  in  the  shafts  of  the  long  hones.  'The  former  is  a  primary  disease  among 
children,  the  latter  more  commonly  the  result  of  a  previous  attack  of  diffuse 
osteomyelitis.      The   primary  epiphysitis   is  often  multiple.      The  chief  symp- 


188  DISEASES    OF   BONES 

torn  is  pain  of  an  intense  boring  character,  worse  at  night  and  after  using 
the  limb.  Tenderness  is  present  over  the  abscess,  and  is  due  to  secondary 
periostitis.  The  disease  is  apt  to  rim  rather  a  chronic  course,  and  only  in 
acute  cases  are  constitutional  symptoms  marked.  Secondary  involvement  of 
joints  and  destruction  of  the  epiphyseal  cartilage  with  separation  of  the  epiphy- 
sis will  give  rise  to  characteristic  symptoms.  Such  involvement  is  occasional. 
Locally  there  will  often  be  little  beyond  the  pain  and  tenderness  to  indicate 
the  cause  of  the  trouble,  unless  a  secondary  periostitis  occurs  with  abscess  of 
the  soft  parts,  or  unless  a  neighboring  joint  or  the  epiphyseal  cartilage  is 
invaded.  In  many  instances,  as  already  noted,  a  differential  diagnosis  from 
tuberculosis  may  not  be  practicable  without  operation.  The  chronic  osteo- 
myelitis of  the  shafts  of  the  long  bones  will  usually  have  the  history  of  a 
previous  attack  of  acute  bone  inflammation  or  of  a  bone  injury  complicated  by 
infection.  In  the  presence  of  a  sinus  leading  to  an  ancient  sequestrum  or  a 
chronic  suppurating  bone  cavity  the  diagnosis  is  plain.  When  no  such  open 
lesion  exists,  pain  will  be  the  prominent  and  sometimes  the  only  symptom. 
Tenderness  will  be  present  over  the  focus  if  periostitis  coexists,  and  will  serve 
as  a  guide  for  surgical  interference.  Periosteal  thickening  is  usually  present 
in  these  cases,  and  gives  the  physical  signs  of  an  enlargement  of  the  bone. 

TUBERCULOUS   OSTEOMYELITIS 

Tuberculosis  of  the  bones  so  often  affects  their  epiphyses,  and  is  so  often 
associated  with  secondary  joint  tuberculosis,  that  much  that  has  been  said  under 
tuberculosis  of  joints  applies  also  to  tuberculosis  of  bone.  Occurring  as  a 
separate  affection  independent  of  joint  disease,  tuberculosis  affects  the  epiphyses 
commonly,  more  rarely  the  shafts  of  the  long  bones  or  the  bodies  of  flat  or 
spongy  bones.  The  disease  affects  males  more  commonly  than  females,  and 
is  a  disease  of  childhood  and  youth.  Other  foci  of  tuberculosis  are  often 
present  or  appear  later  in  life.  In  the  epiphyses  of  the  long  bones  a  tubercu- 
lar focus  may  exist  without  producing  symptoms. 

Signs  and  Symptoms. — Pain. — There  is  usually  pain,  more  or  less  marked, 
but  of  a  variable  intensity  and  intermittent,  of  a  dull  aching  character,  worse 
at  night.  Children  with  beginning  bone  tuberculosis  often  wake  crying,  or 
are  restless,  grind  their  teeth,  or  have  bad  dreams.  The  pain  is  sometimes 
a  referred  pain,  a  classical  example  being  the  pain  of  tuberculosis  of  the  upper 
end  of  the  femur,  usually  referred  to  the  knee.  On  the  other  hand,  in  the 
phalanges  of  the  fingers  a  central  tubercular  focus  may  occupy  the  entire 
phalanx,  and  produce  the  characteristic  spindle-shaped  enlargement  (Spina 
ventosa)  and  be  accompanied  by  no  pain.  Tuberculous  osteites  of  the  ribs 
are  rarely  painful. 

Tenderness. — The  most  important  diagnostic  sign  in  the  detection  of 
early  bone  tuberculosis  is  tenderness  over  the  point  of  disease  in  the  bone. 
It  is  caused  by  a  secondary  periostitis,  and  a  point  of  tenderness  appearing 


SYPHILIS    OF   BONE  189 

over  the  epiphyseal  end  of  a  long  bone  in  a  child,  enduring  for  a  time  and 
slowly  growing  more  marked,  is  very  suggestive  of  tuberculosis  of  the  bone. 
If  joint  involvement  can  be  excluded,  the  moment  is  often  most  favorable  for 
the  operative  eradication  of  the  disease. 

Swelling. — The  presence  of  a  tuberculous  focus  in  the  epiphysis  of  a 
long  bone  does  not  cause  swelling  or  enlargement  of  the  bone ;  such  swelling 
as  occurs  is  due  to  thickening  of  the  periosteum  or  infiltration  of  the  soft  parts. 
In  the  shafts  of  long  bones,  on  the  other  hand,  a  localized  or  diffuse  swelling 
occurs  when  cortical  bone  absorption  goes  on  hand  in  hand  with  a  periostitis. 
Such  periostitis  may  produce  enough  new  bone  to  preserve  the  hardness  of  the 
cortical  layer,  or  a  parchment  crackling  may  be  felt  upon  firm  pressure,  or,  in 
more  advanced  cases  when  the  bone  is  perforated,  a  secondary  tuberculous 
abscess  of  the  soft  parts  forms,  a  boggy  or  fluctuating  swelling  having  the 
characters  of  cold  abscess,  as  elsewhere  described. 

Redness. — ]STo  redness  of  the  skin  is  seen  over  a  tuberculous  focus  in 
bone  unless  the  skin  is  about  to  be  perforated  by  tuberculous  pus.  A  bluish 
or  purple  discoloration  of  the  skin  is  then  observed,  not  a  vivid  red,  such  as 
one  sees  in  acute  infections. 

Atrophy. — Atrophy  of  all  the  tissues  of  a  limb  is  a  regular  complication 
of  those  forms  of  tuberculosis  of  the  bones  and  joints  which  involve  disuse 
of  the  limb. 

If  a  tuberculous  focus  is  suspected  in  the  epiphysis  or  of  the  shaft  of  a 
long  bone,  an  aspirating  needle  or  small  trocar  may  sometimes  be  used  to  con- 
firm the  diagnosis.  The  withdrawal  of  tuberculous  pus  or  cheesy  material, 
or  the  discovery  of  a  cavity  in  the  bone  by  this  means,  should,  if  possible,  imme- 
diately precede  the  operative  removal  of  the  focus.  A  good  X-ray  picture  will 
often  show  such  foci  quite  distinctly.  Should  a  sinus  exist,  the  introduction 
of  a  probe  will  often  serve  to  detect  rough  carious  bone  or  a  bone  cavity.  This 
method  of  examination  should  be  followed  at  once  by  operation  on  account 
of  the  danger  of  destroying  the  protecting  layer  of  granulation  tissue  lining 
such  cavities,  and  thus  causing  local  or  general  infection  with  tubercle  bacilli 
or  pus  microbes. 

SYPHILIS    OF   BONE 

Syphilitic  inflammation  of  bone  occurs  in  the  later  stages  of  both  the 
acquired  and  hereditary  forms  of  the  disease.  The  characteristic  lesions  are 
gummatous  periostitis  and  osteomyelitis.  Both  destructive  and  productive 
changes  occur ;  syphilitic  caries  and  necrosis  as  Avell  as  the  production  of 
osteophytes,  osteosclerosis,  and  diffuse  hypertrophies.  The  bones  of  the  skull, 
the  shafts  of  long  bones,  clavicle,  tibia,  femur,  are  favorite  sites.  The  short 
bones  and  the  epiphyses  of  long  bones  are  seldom  affected.  The  lesions  may 
be  single  or  multiple,  and  may  appear  in  one  or  several  bones. 

Syphilitic  Periostitis — Syphilitic  periostitis  occurs  as  a  flat  or  slightly  ele- 
vated, circumscribed,  hard,  elastic  swelling  upon  the  bone.     Although  not  com- 


190 


DISEASES    OF   BONES 


mon  until  after  the  sixth  month  of  the  disease,  such  a  lesion  may  appear  with 
or  soon  after  the  secondary  skin  eruption. 

Pain  and  tenderness  may  be  moderate  or  severe,  and  the  pain  is  worse  at 
night.     The  skin  is  normal  in  appearance  over  the  swelling.     The  process  may 

end  in  the  production  of  new  bone  by  the 
inflamed  periosteum ;  a  rounded  bony  ele- 
vation is  thus  formed,  and  these  syphilitic 
nodes,  as  they  are  called,  are  permanent. 
In  other  cases  degenerative  changes  in  the 
new-formed  gummatous  tissue  occur.  The 
swelling  becomes  more  prominent  and  soft- 
er, elastic,  and  even  fluctuating.  The  skin 
becomes  red  and  infiltrated,  and  finally 
breaks  down,  leaving  a  round  crater-form 
ulcer  with  undermined  edges.  The  base  of 
the  ulcer  consists  of  characteristic  gummy 
material,  resembling  somewhat  raw  bacon 
in  appearance.  At  the  bottom  of  the  cra- 
terlike cavity  the  bone  is  rough  and  eroded. 
Upon  healing,  rounded  scars  are  left  be- 
hind, firmly  adherent  to  the  bone.  Along 
with  the  bone  destruction  there  is  often  a 
productive  osteitis  around  the  edges  of  the 
gumma  with  nodular  thickening  and  sclero- 
sis of  the  spongy  tissue. 

Favorite  sites  for  these  gummata  are 
the  frontal  bone  and  the  crest  of  the  tibia. 
The  smooth  contour  of  the  anterior  surface 
of  the  tibia  and  the  even  line  of  the  crest 
are  permanently  deformed  by  the  formation 
of  grooves,  ridges,  and  bony  nodules.  The 
presence  of  these,  together  with  the  adher- 
ent scars,  constitute  a  character  picture  of 
a  formerly  active  syphilitic  process.  In 
certain  situations,  notably  the  phalanges 
of  the  fingers,  the  nasal  bones,  and  the 
hard  palate,  the  entire  periosteum  of  the 
bone  may  be  involved,  the  nutrition  of 
the  bone  may  be  thus  impaired  to  the  extent  that  necrosis,  complete  or  par- 
tial, takes  place  with  the  slow  separation  of  a  phalanx,  the  nasal  bones  or  the 
whole  or  a  portion  of  the  hard  palate  as  a  sequestrum.  Characteristic  deform- 
ities are  produced.  (See  Regional  Sergury.)  The  effect  of  treatment  upon 
gummatous  periostitis  in  its  early  stages  is  curative;  the  bony  nodes,  once 
formed,  are,  however,  permanent. 


Fig.  42. — Syphilitic  Periostitis  of  the 
Shafts  of  the  Radius  and  Ulna, 
Showing  Slight  Periosteal  Thick- 
ening. The  picture  was  taken  very 
early  in  the  development  of  the  lesion. 
The  initial  lesion  had  occurred  two 
years  before.  Chief  symptom  com- 
plained of,  pain  of  a  dull,  aching 
character,  worse  at  night,  slight  ten- 
derness on  pressure  over  the  lower  half 
of  the  radius  and  ulna.  Rapid  disap- 
pearance of  symptoms  by  the  use  of 
iodid  of  potash  and  mercury.  (Au- 
thor's case.) 


SYPHILIS    01     l 


191 


Syphilitic  Osteomyelitis. — The  inflammations  of  the  bone  substance  itself 
iii.i;.  be  in  the  form  of  circumscribed  gummata,  of  diffuse  gummatous  inflam- 
mation, or  of  a  productive  osteitis.  These  lesions  are  commonly  associated  with 
periostitis,  also  of  :i  productive  character;  hyperostoses,  enlargements,  thick- 
enings of  the  affected  bone  are  produced.  The  gummatous  process  is,  on  the 
oilier  hand,  primarily  destructive  and  associated  wiili  bone  absorption.  This 
combination  of  destruction  and  formative  inflammation  causes  quite  charac- 
teristic bone  changes — the  bone  Is  enlarged,  its  normal  outlines  are  destroyed, 
the  surface  rough  and  worm-eaten  in  appearance,  cavities  arc  formed  here  and 


In;.   43. — Productive  Syphilitic  Osteitis  of    Ulna,  Showing  Great  Enlargement  of    Hone. 
Chief  symptom  pain;  initial  lesion  seven  years  before.     (Author's  case.) 


there,  and  it'  the  entire  shaft  of  a  Lone  is  occupied  by  a  gumma  spontaneous 
fracture  may  occur,  sometimes  in  several  bones  in  succession.  The  appear- 
ance of  these  syphilitic  bones  is  so  characteristic  as  to  be  unmistakable,  and  in 

the  dried  bones  of  ancient  graves  we  can  thus  recognize  the  existence  of  syphilis 
among  the  earlier  races  of  men. 

Gummatous  osteomyelitis  may  exist  for  long  periods  without  objective 
signs.  The  characteristic  bone  pains,  worse  at  night  and  sometimes  of  a  severe 
and  torturing  character,  are  nearly  always  present  Percussion  over  the  affi 
area  is  painful.  The  objective  signs  observed  may  be  a  spontaneous  fracture. 
This  may  occur  very  early,  even  before  severe  pain  has  been  felt,  and  may  be 
the  first  evidence  of  serious  hone  disease.  More  commonly  the  secondary  pro- 
ductive periostitis  leads  t<>  a  more  or  less  fusiform  enlargement  of  the  shat'r 
of  the  hone.  Later,  if  untreated,  softening  and  perforation  of  soft  parts  leads 
to  the  formation  of  abscesses  and  sinuses,  which  discharge  broken-down  gummy 
material,  thin  pus,  and  fine  hone  detritus,  so-called  hone  sand.  A  probe  intro- 
duced into  such  a  sinus  often  penetrates  deeply  int..  the  medulla  of  the  bone, 
and  touches  here  crumbling  cancellous  tissue  and  there  a  hard  sequestrum. 

Syphilitic  Osteomyelitis  of  Flat  Bones. — Syphilitic  osteomyelitis  of 
tlal  hones,  such  as  the  hones  <d'  the  skull,  presents  a   rather  different   picture. 


192 


DISEASES    OE   BONES 


A  painful,  tender,  hard,  rounded  swelling  appears,  covered  by  bone;  slowly 
or  rapidly  the  outer  table  of  the  skull  is  perforated,  the  tumor  becomes  softer, 
and  finally  fluctuates;  the  overlying  skin  becomes  brownish-red  in  color  and 
ulcerates;   broken-down  gummy  material  is   discharged;    a  crater-form   ulcer 

is  left  behind,  extending  deep  into 
the  bone;  further  ulceration  fol- 
lows, and  the  internal  table  is 
sometimes  perforated.  These  per- 
forations are  often  round  or  oval 
in  shape,  and  may  be  large  or 
small.  If  the  hard  palate  was  in- 
volved, an  abnormal  communica- 
tion remains  between  the  mouth 
and  the  nose.  If  the  vault  of  the 
skull,  the  distention  of  the  internal 
table  may  produce  symptoms  of 
compression  of  the  brain.  The 
rapidity  of  the  process  in  syphilitic 
osteomyelitis  varies  within  wide 
limits ;  generally  speaking,  the 
process  is  slow,  and  may  extend, 
with  exacerbations,  over  months 
and  years;  on  the  other  hand, 
notable  bone  destruction  may  take 
place  in  a  few  weeks. 
Differential  Diagnosis. — In  regard  to  the  differential  diagnosis  between  bone 
syphilis,  acute  osteomyelitis,  tuberculosis,  subacute  or  chronic  osteomyelitis, 
and  malignant  new  growths,  it  may  be  said  that  acute  osteomyelitis  runs  a  far 
more  rapid  and  acute  course,  and  is  not  attended  by  enlargement  of  the  affected 
bone,  though  the  swollen  periosteum  may  cause  apparent  enlargement,  (See, 
however,  Periostitis,  Albumenosa,  and  Sclerosing  Osteomyelitis.)  Chronic  and 
subacute  osteomyelitis  nearly  always  follows  an  acute  attack.  Tuberculosis 
affects  the  epiphyses  in  a  large  proportion  of  cases.  Malignant  new  growths 
cause,  as  a  rule,  a  more  rapid  enlargement  of  the  bone,  with  more  sharply 
marked  boundaries.  One  of  the  best  means  of  diagnosis  in  bone  syphilis  is  the 
administration  of  inunctions  of  mercury  and  of  increasing  doses  of  potassium 
iodid,  pushed  until  the  limit  of  tolerance  is  reached.  Syphilitic  lesions  will 
be  cured  or  improved  by  this  means.  Bone  of  new  formation  cannot  be  made 
to  disappear,  nor  can  sequestra  be  removed  in  this  way,  but  pain  will  be  less- 
ened or  cured,  ulcerations  will  heal,  gummata  and  periosteal  infiltrations  will 
fade  away,  and  the  clinical  picture  will  nearly  always  change  for  the  better. 
Nonsyphilitic  processes  will  be  unaffected. 

Bone  Lesions  of  Hereditary  Syphilis. — Bone  lesions  may  make  their  appear- 
ance during  infancy,  or  even  before  birth,  or  they  may  be  delayed  until  ado- 


flg.    44. gummatous     inflammation     of     the 

Frontal    Bone    with    Perforation    of    the 
Skull.     (New  York  Hospital  Museum.) 


RACHITIS  193 

lescence — four  to  fifteen  years.  One  of  the  mosl  frequenl  forms  <  1 1 1  r  I  n  «j-  Infanl 
life  and  childhood  is  an  inflammation  «>t'  the  epiphyses  of  the  long  bones  in- 
volving the  epiphyseal  cartilage  an  osteochondritis,  sometimes  attended  by 
destruction  of  the  cartilage  and  separation  of  the  epiphysis.  Tibia,  radius,  and 
ulna  and  humerus  arc  the  bones  usually  affected.  A  fusiform  or  ring-shaped 
swelling  is  formed  at  the  junction  of  the  epiphysis  with  the  shaft.  The  de- 
formity is  not  unlike  thai  produced  by  rachitis.  The  bone  adjoining  the 
cartilage  is  softened,  and  its  continuity  may  be  preserved  by  the  thickened 
periosteum  merely.  Spontaneous  fracture  or  diastasis  may  occur  from  slight 
degrees  of  violence.  There  is  commonly  severe  pain  and  tenderness  along  the 
epiphyseal  line;  the  child  screams  violently  when  the  pari  is  pressed  upon.  The 
limli  is  powerless  and  is  nol  moved  (  Pseudoparalysis  syphilitica — Parrol  I.  In 
case  the  epiphysis  becomes  separated  from  the  shaft,  a  poinl  of  abnormal  mobil- 
ity can  be  felt,  bu1  crepitation  is  often  absent.  Angular  deformities  a1  the  junc- 
tion of  tlic  ribs  with  their  cartilages  and  at  the  ends  of  the  long  bones  of  the  ex- 
tremities may  follow.  Suppuration  is  not  infrequent,  the  soft  parts  overlying 
the  joint  become  swollen,  edematous,  and  of  a  pasty  consistence.  Ulceration 
follows,  of  a  typical  syphilitic  character;  sometimes  the  neighboring  joint  be- 
comes  involved  in  the  inflammation.  Tn  case  the  vital  connection  of  cartilage 
between  shaft  and  epiphysis  is  destroyed,  the  growth  of  the  bone  is  interfered 
with.  In  some  cases  the  process  is  of  a  more  irritative  character;  an  over- 
growth of  hone  takes  place;  the  bone  becomes  Ionizer  than  normal.  Tn  syphil- 
itic children,  from  the  fourth  year  upward  syphilitic  periostitis  of  the  forma- 
tive variety  is  not  infrequent.  The  tibia  is  often  the  seat  of  the  process.  The 
bone  becomes  enlarged,  thickened,  and  deformed;  the  normal  outlines  are  lost; 
anterior  curvature  is  common,  as  well  as  flattening  from  side  to  side.  Knock- 
knee  and  tl a t-foot  sometime-  result  from  uneven  growth  of  the  tibia  and  fibula. 
In  hereditary  syphilis  of  the  late  type — i.  e.,  symptoms  first  developed,  from 
the  fourth  to  the  eighteenth  year — the  hones,  the  permanent  teeth,  and  the 
cornea  are  affected  in  a  considerable  proportion  of  cases.  The  bone  lesions  are 
as  described.  The  narrow,  short,  central  incisor  teeth,  with  rounded  notches 
upon  their  cutting  edges,  and  keratitis,  form,  when  present,  an  unmistakable 
group  of  ->  mptoms. 

RACHITIS 

Rickets  is  a  disease  of  the  general  nutrition  occurring  in  infants  and 
young  children  up  to  the  age  of  puberty.  It  is  supposed  to  be  due  to  im- 
perfect feeding  during  the  first  year  of  life,  early  weaning,  too  much  starchy 
food,  etc.  The  disease  may  he  evident  at  birth  (achondroplasia,  fetal  rachi- 
tis), more  commonly  it  develops  during  the  first  two  or  three  year-  of  life. 
The  symptoms  are  local  and  general.  The  genera]  symptoms  are  disturb- 
ances of  the  bowels,  diarrhea  or  constipation,  a  prominent  belly;  profuse 
sweating,  notably  about  the  head  and  at  night;  bronchitis,  delayed  denti- 
tion, delayed  closure  of  the  fontanels.  The  liver  may  be  diminished  in 
14 


194 


DISEASES    OF   BONES 


The  spleen  is  sometimes  enlarged.  Phosphaturia  is  commonly  observed. 
Ckronic  kydrocepkalus  and  arrest  of  or  imperfect  cerebral  development  are 
not  infrequent. 


Fig.  45. 


Fig.  46. 


Figs.  45  and  46. — Photographs  of  a  Case  of  Achondroplasia  Congenita,  So-called  Fetal  Ra- 
chitis. The  patient  was  a  woman  aged  about  thirty  years.  Nearly  all  the  bones  of  the  skeleton 
were  of  abnormal  shape  or  abnormally  proportioned.  There  was  a  very  marked  exaggeration 
of  the  dorsal  curve  of  the  spine  and  marked  lordosis  in  the  lumbar  region.  The  antero-posterior 
diameter  of  the  pelvic  brim  was  not  more  than  one  and  one  half  inches.  The  patient  was  very 
intelligent  and  enjoyed  excellent  health. 


Rackitic  ckildren  are  peculiarly  liable  to  attacks  of  spasm  of  tke  larynx 
(Laringismus  stridulus).  Tke  ckild  does  not  learn  to  walk  readily.  Eitker 
with  tkese  signs  and  symptoms,  or  later,  tkere  are  developed  peculiarities  and 
deformities  of  tke  bony  skeleton.  Tkere  is  imperfect  ossification  and  enlarge- 
ment at  junctions  of  tke  skafts  of  tke  long  bones  witk  tkeir  epipkyses;  tke 
lower  end  of  tke  radius,  tke  lower  end  of  tke  tibia,  and  tke  ribs  at  tke  costo- 
ckondral  junctions  show  fusiform  swellings.  The  skull  departs  from  the  nor- 
mal shape.  The  calvarium  is  often  higher  than  normal,  and  is  compressed 
either  antero-posteriorly  or  laterally ;  the  fontanels  remain  open  sometimes  until 


RACHITIS 


195 


the  «'H<1  of  the  second  year ;  the 
top  "I"  the  skull  may  remain  im- 
perfectly ossified,  and  in  parts 
remain  "I"  ;i  parchmentlike  con- 
sistence i  <  Iraniotabes  rachitics  i. 
I  triii ii ion  is  delayed,  imperfect, 
or  irregular;  there  is  commonly 
a  gothic  or  arched  hard  palate. 

Tin'  antero-posterior  diam- 
eter <>t*  the  thorax  i-  increased 
in  its  upper  part  and  com- 
pressed laterally;  the  sternum 
is  prominenl  and  the  costochon- 
dral  junctions  are  enlarged  ami 
palpable;  there  is  a  groove  along 
the  line  between  the  ribs  ami 
their  cartilages;  the  lower  rilis 
project     outwardly,      thus     the 


I'k;.  48. — A  Marked  Condition  of  Knock- 
Knee  Associated  with  Rachitis.  The 
enlargement   of  the  epiphyseal  ends  <>f  the 

til)i:i  aiul  fibula  at  the  ankle-joint  are 
well  shown.  (Collection  of  Dr.  Charles 
McBurney,   Roosevell   Hospital.) 


Fig.  47. — A  Marked  Condition  of  Bow-leos 
(Genu  Varum).  (Collection  of  l>r.  Charles 
McBurney  of   Roosevelt  Hospital.) 


transverse  diameter  of  the  thorax  i- 
increased  at  its  lower  part.  Deformi- 
ties of  the  pelvis  are  common  and  en- 
dure through  life.  The  antero-poste- 
rior diameter  of  the  pelvic  girdle  is 
diminished,  or  le<<  often  the  pelvis  is 
compressed  laterally  so  that  the  supe- 
rior opening  of  the  pelvis  has  a  shape 
resembling  that  of  the  ace  of  heart-. 
Curvatures  of  the  femur  and  of  the 
tibia  and  fibula  are  common.  The 
curvature  of  the  femur  may  he  convex 
anteriorly  or  to  the  outer  side.  The 
tibia  is  often  curved  outwardly  (Genu 
varum — bow-legs)  or  anteriorly;  the 
crest    of  the   tibia   then   appears   prom- 


196 


DISEASES    OF   BONES 


inent,  and  the  bone  may  be  compressed  laterally.  Sometimes  combinations  of 
anterior  and  lateral  curvatures  occur ;  genu  valgum  is  less  common.  The  spine 
often  shows  a  lateral  curvature  (scoliosis)  or  an  anteroposterior  curvature 
(lordosis  or  kyphosis). 

All  these  deformities  are  so  characteristic  that  the  diagnosis  of  rickets  is 
usually  very  simple.     It  is  only  necessary  to  remove  the  clothing  from  the  child 

and  inspect  its  naked  body  to  rec- 
ognize the  more  typical  cases  of  the 
disease.  After  these  patients  grow 
older  and  ossification  is  complete 
their  bones  may  become  exceed- 
ingly dense  and  hard. 

OSTEOMALACIA 

Osteomalacia  is  a  rarefying  os- 
teitis, combined  with  loss  of  earthy 
material  of  the  bone.  It  is  a  com- 
paratively rare  disease,  occurring 
in  women  during  and  after  preg- 
nancy. Two  sets  of  phenomena  are 
observed:  the  bones  may  undergo 
spontaneous  fracture  from  very 
slight  degrees  of  violence,  or  the 
bones  become  so  soft  that  bends 
and  deformities  of  the  long  bones 
occur  in  all  directions  and  to  ex- 
traordinary degrees.  In  addition, 
neuralgic  pains  of  severe  character 
are  present,  together  with  progres- 
sive cachexia,  usually  leading  to  a 
fatal  issue  in  a  year  or  two. 


Fig.  49. — Case  of  Acromegaly  Occurring  in  the 
Service  of  Dr.  Frank  W.  Jackson  in  Belle- 
vue  Hospital,  through  whose  Kindness  I 
am  Able  to  Have  the  Accompanying  Illus- 
trations Reproduced. 

Note. — The  pathological  report  of  this  case  was 
published  by  Dr.  Charles  Norris,  who  very  kindly 
gave  me  the  photographs.  The  patient's  symp- 
toms had  existed  for  nearly  five  years  and  con- 
sisted in  a  gradual  and  characteristic  enlargement 
of  the  hands,  the  feet,  and  the  face;  together  with 
dimness  of  vision  due  to  atrophy  of  the  optic  nerve. 
During  the  last  year  of  his  life  he  had  from  time  to 
time  epileptic  convulsions  and  continuous  head- 
ache. His  mental  faculties  were  impaired,  as  shown 
by  progressive  loss  of  memory  and  by  fits  of  irrita- 
bility. He  died  in  Bellevue  Hospital  in  January, 
1907.  Death  was  preceded  by  a  series  of  severe 
convulsions  after  which  the  patient  became  coma- 
tose, with  Cheyne-Stokes  respiration  and  died. 
The  case  was  reported  in  full  by  Dr.  Charles  Norris 
in  the  "Proceedings  of  the  New  York  Pathological 
Society."     New  Series,  vol.  vii,  No.  1. 


OSTEITIS    DEFORMANS 

Osteitis  deformans  is  a  rarefy- 
ing osteitis  affecting  the  entire  skel- 
eton ;  the  disease  affects  males  more 
often  than  females,  and  does  not 
occur  until  near  the  fiftieth  year 
of  life.  The  characteristic  signs  are  pain  in  the  affected  bones,  enlargements 
and  curvatures  of  the  bones  of  the  extremities,  progressive  muscular  weak- 
ness. The  onset  of  the  condition  is  slow  and  insidious.  The  tibia  and  femur 
are  first  affected ;  they  become  thickened  and  bowed  anteriorly.      Subjectively 


ACROMEGALY 


197 


the  limbs  feel  heavy,  and  locomotion  becomes  difficull  from  muscular  weakness 
;ind  pain.  Tin1  bone  changes  can  be  well  shown  by  ;i  radiograph.  In  a  case 
tinder  my  observation  the  tibia  was  notably  enlarged  and  bowed  anteriorly. 
The  X-ray  picture  showed  thinning  of  the  cortical  layer,  a  marked  increase 
in  size  of  tin1  spnccs  of  the  cancellous  tissue,  and  the  formation  of  irregularly 
shaped  cavities  in  the  can 
cellous  tissue  bounded  by 
thin,  bony  lamella?.  As  the 
disease  progresses,  other 
bones  are  affected.  The 
spine  loses  its  flexibility, 
and  is  bowed  forward  so 
thai  the  pal  ient's  chin  pro- 
jects, while  the  t horax  sinks 
toward  the  pelvis.  The 
shoulders  are  rounded  and 
I  lie  arms  hang  forward,  and 
lower  than  normal.  The  at- 
titude suggests  thai  of  some 
of  the  manlike  apes.  The 
muscular  weakness  and  de- 
formity continue  slowly  to 
increase  ;  death  occurs  final- 
ly from  exhaustion  or  from 
some  intercurrent  disease. 


Fiq.  51. 


FlGS.  50  and  51. — The  Brain  of  Patient  in  Cask  Shown   in    I'm.    19,  Snow  in.;   Hi  sri  <  iivki.i   thi 
Base  of  the  Brain,  with  the  Tumor  in  Situ  and  a  Frontal  Section  of  the  Brain  throi  qh 

the  Tumor  of  the  Pituitary  Body. 


ACROMEGALY 


Acromegaly  is  a   disease  of  obscure  nature,  and    rather  rare,  commencing 
during  the  second  or  third  decade  of  life,  and  characterized  by  an  hypertrophy 


198  DISEASES    OF   BONES 

of  the  bones  and  soft  parts  of  the  hands,  forearms,  face,  and  feet,  and  by 
disturbances  of  the  mental  state :  mental  dullness,  emotional  disturbances,  some- 
times melancholia.  The  nervous  reflexes  are  disturbed — sometimes  exaggerated, 
sometimes  diminished.  There  is  muscular  weakness  and  a  general  enfeeblement 
of  the  entire  organism.  The  appearance  of  these  people  is  so  characteristic 
that  a  diagnosis  can  usually  be  made  at  a  glance  (see  illustration).  The  face, 
notably  the  lower  portion  including  the  lower  jaw,  is  abnormally  large;  the 
exjjression  is  dull  and  listless.  The  hands,  forearms,  and  feet  are  abnormally 
large.  The  skin  is  normal  in  appearance.  The  disease  is  sometimes  associated 
with  malformations  of  the  sexual  glands  and  enlargement  of  the  pituitary  body. 

LEONTIASIS   OSSIUM 

Another  obscure  condition  is  Leoxtiasis  Ossiitm.  There  is  a  diffuse  hyper- 
trophy of  the  bones  of  the  face,  notably  of  the  upper  jaw,  and  the  formation 
of  circumscribed  outgrowths  of  cancellous  bone  tissue  in  the  same  region.  These 
bony  masses  cause  serious  symptoms  by  pressure  in  the  orbit,  in  the  nasal 
fossa?,  and  the  base  of  the  skull,  interference  with  respiration  and  vision,  or, 
by  growing  into  the  cranial  cavity,  cerebral  symptoms  from  compression  of 
the  brain. 


CHAPTER    VI 

DISEASES   OF  THE   SOFT    PARTS 

GANGRENE 

Death  of  circumscribed  masses  of  tissue — variously  known  as  gangrene, 
mortification,  necrosis,  sloughing,  sphacelation — occurs  when  the  tissue  cells 
are  deprived  of  their  proper  nutrition  <>r  are  killed  by  mechanical,  chemical, 
or  other  means.    The  term  gangrene  is  commonly  used  to  describe  the  condition 

of  death  when  associated  with  the  phenomena  of  decomposition  (  mortification  I, 
and  indicates  that  putrefactive  changes  have  occurred  in  the  dead  part.  The 
dead  part  is  known  as  a  sphacelus  or  slough.  Necrosis  i>  commonly  used  to 
designate  the  death  of  bone  or  the  death  of  a  limited  portion  of  tissue  without 
decomposition. 

Causation. — Gangrene  may  occur  from  a  variety  of  causes:  Cessation  of 
the  blood  supply  to  the  part  by  obstruction  of  the  main  artery  of  a  limb.  Ob- 
struction of  the  veins  such  that  the  blood  cannot  return  to  the  general  circu- 
lation. Obstruction  of  both  arteries  and  veins.  Obstruction  of  the  smaller 
arteries  and  veins  or  of  the  capillaries.  The  obstruction  may  be  due  to  injury 
of  the  vessels  themselves,  as  when  the  main  artery  of  a  limb  is  crushed,  torn, 
cut,  or  ligated.  It  may  be  clue  to  mechanical  pressure  from  effused  blood 
around  a  ruptured  aneurism,  a  foreign  body,  a  tumor,  a  fractured  or  dis- 
located  bone,  unduly  prolonged  application  of  an  elastic  ligature  around  a 
limb  for  the  control  of  bleeding,  a  circular  plaster-of-Paris  dressing  too 
tightly  applied  in  cases  of  fracture,  or  to  compression  of  the  tissues  between 
bony  points  and  the  bed  in  depressed  states  of  vitality.  Further,  diseases 
of  the  blood-vessels:  thrombosis,  embolism,  obliterating  arteritis,  arterio- 
sclerosis. 

Numerous  other  conditions  not  directly  connected  with  the  blood-vessels 
themselves  may  cause  or  predispose  to  the  occurrence  of  gangrene.  Crushing 
injuries  destroy  the  vitality  of  the  tissue  cells.  Bacterial  invasion  of  wounds 
is  a  direct  cause  of  gangrene  in  some  cases;  iu  others  the  bacterial  poisons  act 
in  conjunction  with  general  or  local  states  of  enfeebled  vitality.  Extreme 
degrees  of  heat  and  cold  destroy  the  vitality  of  the  ti>>tie  cells.  Certain  poisons 
and  caustics — snake  venom,  carbolic  acid,  nitric  acid,  etc. — produce  coagulation 
of  the  tissue  elements  and  necrosis.  The  radiations  from  an  X-ray  tube  may 
cause  sloughing  of  the  tissues.     Predisposing  causes  of  gangrene  are  extreme 


200 


DISEASES    OF    THE    SOFT    PAETS 


anemia,  acute  or  chronic  alcoholism,  senility,  diabetes,  diseases  of  the  heart 
and  lungs  or  vessels  producing  venous  congestion,  acute  infectious  diseases. 
Further,  certain  diseases  of  the  nervous  system :  tabes,  cerebral  palsies,  division 
of  nerve  trunks,  and  diseases  of  the  trophic  nerves.  These  various  conditions, 
combined  with  mechanical  injury  and  bacterial  infection,  often  determine  the 
occurrence  of  gangrene. 

Symptoms. — Clinically  the  local  and  general  signs  and  symptoms  of  gan- 
grene vary  a  good  deal,  according  to  the  character  of  the  affected  tissue  and  its 

relation  to  the  neighboring  living 
parts ;  further,  according  to  the 
presence  or  absence  of  bacterial 
infection,  putrefactive  or  pyogen- 
ic, one  or  both.  When  the  arte- 
rial circulation  of  a  part  slowly 
ceases  while  the  veins  remain 
patent,  but  little  water  remains 
in  the  tissues,  and  the  conditions 
are  unfavorable  for  putrefactive 
change.  Such  conditions  are 
present  in  the  gangrene  of  the 
toes  and  feet  of  old  people,  due 
to  slowly  progressive  arterio- 
sclerosis of  the  vessels  of  the 
foot  and  leg.  In  some  of  these 
cases  a  spreading  thrombosis  of 
the  capillaries  and  arterioles 
stops  the  circulation.  In  others, 
thrombosis  of  the  larger  arteries 
is  found  together  with  advanced 
atheroma  of  these  vessels  (Gan- 
geena  senilis).  In  many  of 
these  cases  the  gangrene  is  of  the 
dry  aseptic  type  (dry  gangeene 
— mummification)  . 

Course  of  the  Disease. — Pro- 
dromal symptoms  may  precede ; 
there  is  subjective  and  objective 
coldness  of  the  toes;  pain,  some- 
times dull,  sometimes  sharp  and 
neuralgic  in  character.  Such 
symptoms  may  be  present  for  weeks  or  months,  or  the  gangrene  may  occur 
without  warning.  After  some  trifling  contusion  or  abrasion,  or  without  such, 
a  spot  of  dusky  discoloration  appears  upon  a  toe,  and  slowly  increases  in  size, 
gradually  involving  one,  several,  or  all  the  toes  or  a  large  part  of  the  foot. 


Fig.  52. — Dry  Gangrene  of  the  Foot. 
(New  York  Hospital,  service  of  Dr.  Frank  Hartley.) 


GANGRENE  201 

The  dead   tissue   is   dark  greenish-biown   in  color,   hard,   dry,   shriveled,   and 
insensitive.     Putrefactive  changes  are  slighl  or  absent. 

A  line  of  demarcation  between  the  living  ;m<l  the  dead  tissue  i-  formed  in 
many  of  these  cases.  The  upper  third  of  the  calf  of  the  leg,  In-low  the  bifur- 
cation of  the  popliteal  artery,  is  rarely  passed  in  this  form  of  gangrene.  The 
dark-colored  dead  tissue  ends  abruptly  al  a  certain  level;  above  thai  the  -kin 
is  reddened,  hot  and  tender;  a  furrow  forms  by  ulceration  nt  the  border  <>t 
the  living  tissues  and  encircles  the  limb,  gradually  growing  deeper  until  the 
soft  parts  are  entirely  separated  and  the  dead  pari  remains  attached  to  the 
living  merely  by  bone.  Moderate  suppuration  accompanies  the  separation,  as 
a  rule.  The  skin  usually  dies  at  a  higher  level  than  the  muscles,  and  the  mus- 
cles at  a  higher  level  than  the  bone;  hence,  spontaneous  separation  lei 
behind  ;i  «••  >i  1  i<-;i I  stump.  It'  nearly  aseptic,  this  type  of  gangrene  may  be 
accompanied  by  little  or  no  constitutional  disturbance. 

M  <  >  I  ST    GANGS  E  N  E T  RAU  M  A.TIC     Ga  N  GB  I :  N  I . 

Moist  gangrene  is  accompanied  by  putrefactive  changes  in  the  dead  tissues, 
and  is  of  ten  associated  with  pyogenic  infection.  The  gangrene  following  trauma 
is  often  of  iIk'  moist  variety.  Moist  gangrene  may  be  localized  or  progressive. 
It  occurs  when  the  dead  tissues  remain  saturated  with  fluid,  thus  favoring 
putrefaction.  Sudden  obstruction  of  the  main  artery  or  vein,  or  both,  of  a 
limb  from  injury  or  disease,  severe  trauma  with  much  contusion  and  lacera- 
tion of  tissue,  are  the  usual  causes  of  moist  gangrene.  The  determining  factor 
is  always  the  presence  of  infection  with  saprophytic  and  pyogenic  germs. 

Signs  and  Symptoms  of  Localized  Moist  Gangrene. —  Pain  in  the  part  ceas 
the  limit  becomes  cold,  white,  pulseless,  insensitive,  and  useless.  Coagulation 
of  the  muscle  plasma  causes  rigidity  of  the  muscle-  |  rigor  mortis),  lasting  for 
some  hours.  The  skin  surface  becomes  mottled  with  blue  or  dark-red  blotches. 
A  genera]  greenish-brown  discoloration  follows.  The  living  skin  above  is  red, 
swollen,  tender,  and  hot.  Red  streaks  of  lymphangitis  can  sometimes  be  seen 
running  upward  toward  the  trunk.  Blebs  form  upon  the  skin  of  the  gangrenous 
area  filled  with  brownish,  stinking  fluid,  sometimes  with  gas.  The  dead  tissues 
may  also  crepitate  from  the  generation  of  the  gases  of  putrefaction.  The 
epidermis  forming  the  blebs  can  be  slid  about  easily  upon  the  underlying  green 
or  dark  purplish-red,  softened  cutis.  Upon  cutting  into  the  limb,  blood-stained, 
brown,  stinking  fluid  escapes.  The  muscles  are  sofl  and  pulpy,  at  first  dark- 
red  or  brown  in  color,  later  greenish-black  and  semifluid.  The  further  changes 
are  simply  those  of  advanced  putrid  decomposition,  with  liquefaction.  The 
living  tissues  above  the  limit  of  the  gangrene  are  in  a  condition  of  more  or 
less  acute  purulent  infection.  There  i-  profiler  suppuration  at  the  lit: 
demarcation,  progressive  ulceration  and  final  separation  of  the  dead  part,  or 
death  of  the  individual  from  septic  and  saprophytic  absorption. 


202  DISEASES    OF   THE    SOFT   PAKTS 


Malignant   Edema — Gangrene   Eoudroyante — Emphysematous 

Gangrene 

The  bacillus  of  malignant  edema  (vibrioru  septique  of  Pasteur)  causes  by  far 
the  most  dangerous  and  fatal  form  of  gangrene.  It  is  a  rod-shaped  bacillus,  usu- 
ally with  rounded  ends.  The  rods  vary  in  length  from  3  to  10  /a;  they  are  motile, 
and  possess  flagella  on  the  sides;  sometimes  the  rods  grow  into  long  filaments. 
It  is  an  anaerobic  germ  and  forms  spores.  It  is  not  easy  to  identify  under  the 
microscope. 

In  gelatin  plates,  under  anaerobic  conditions,  the  colonies  appear  as  small 
whitish  points,  which  under  a  low  power  show  radiating  appearances  soon  masked 
by  a  mask  of  liquefaction.  In  deep  tubes  of  glucose  gelatin  the  growth  appears 
as  a  whitish  line,  giving  off  minute  short  processes,  never  reaching  within  an  inch 
of  the  top  of  the  medium,  with  the  occurrence  of  liquefaction  and  the  settling  of 
the  colonies  to  the  bottom.  In  deep  tubes  of  glucose  agar  at  a  temperature  of  37° 
C.  the  growth  is  very  rapid,  as  a  broad  white  line  along  the  line  of  puncture,  with 
lateral  projections  here  and  there  and  a  very  profuse  production  of  gas.  The  cul- 
tures have  a  peculiar  heavy  odor  that  is  quite  characteristic.  The  growth  is  rapid ; 
it  produces  spores  that  are  well  seen  within  forty-eight  hours  at  37°  C. ;  it  pro- 
duces gas,  liquefies  gelatin,  and  stains  easily  with  any  of  the  anilin  colors,  but 
not  by  Gram's  method;  upon  subcutaneous  inoculation  in  any  susceptible  animal 
it  produces  the  characteristic  symptoms  of  widespread  edema,  gas  production,  and 
gangrene. 

Cultures  may  be  made  in  glucose  gelatin  as  roll  cultures,  and  kept  under  anaero- 
bic conditions.  If  the  bacilli  contain  spores  the  fluid  may  be  kept  at  a  temperature 
of  80°  C.  for  ten  minutes,  and  then  a  deep  glucose-agar  tube  should  be  inoculated 
and  kept  at  the  temperature  of  the  body.  An  inoculation  experiment  with  the  sus- 
pected material  may  also  be  tried  on  guinea  pigs.     (H.  C.  Ernst.)     hoc.  cit. 

The  process  is  essentially  a  rapidly  progressive  septic  cellulitis,  with  grave 
constitutional  poisoning,  advancing  hand  in  hand  with  putrid  decomposition 
of  the  infected  tissues.  The  onset  of  the  disease  is  sudden,  following  an  injury, 
a  compound  fracture,  a  gunshot  wound,  or  a  contused  and  lacerated  wound, 
or,  more  rarely,  some  trifling  puncture.  After  a  day  or  two  an  area  of  hard, 
brawny  edema  of  a  dusky-red  or  mahogany  color  appears  at  the  wound  edges 
and  spreads  rapidly  up  the  limb.  Constitutional  symptoms  of  sepsis  appear 
at  once,  and  grow  more  grave  from  hour  to  hour.  The  limb  becomes  greatly 
swollen,  and  from  the  hand  the  necrotic  inflammation  may  reach  the  shoulder 
in  two  days.  Putrid  decomposition  of  the  part  first  affected  takes  place  rapidly, 
and  above  the  gangrenous  area  the  hard,  dark-colored  infiltration  advances. 
Subcutaneous  emphysema  due  to  the  gases  of  decomposition  is  marked,  and 
often  extends  far  beyond  the  inflamed  and  necrotic  area  up  on  to  the  shoulder 
or  to  the  groin  and  abdomen.  Blebs  containing  stinking  serum  and  gas  form 
here  and  there  upon  the  discolored  skin.  Incision  into  the  limb  permits  the 
escape  of  stinking  serum,  but  no  blood.  The  vessels  are  filled  with  septic 
thrombi :  the  connective  tissues  look  like  raw  bacon ;  the  muscles  are  dark-red 


GANGRENE 

or  almost  black,  and  soft  Here  and  there  an  abscess  may  be  encountered, 
filled  with  stinking  pus. 

From  the  firs!  the  septic  Bymptoms  are  grave.  The  temperature  is  :it  first 
elevated,  later  it  often  sinks  to  subnormal;  tin-  pulse  is  rapid,  and  continues 
to  grow  weaker.  Delirium  Boon  appears,  followed  by  stupor  and  coma.  The 
picture  is  thai  of  intense  septic  intoxication,  and  ends  fatally  in  a  large  pro- 
portion of  cases.  A  few  are  saved  by  early  amputation  above  the  limit  of  the 
infection.  Gangrene  with  putrid  decomposition  occasionally  occurs  primarily 
in  the  lung.  In  other  internal  organs,  except  the  alimentary  canal,  emboli 
containing  putrefactive  germs  musl  be  broughl  to  the  pari  for  the  production 
of  this  form  <>f  necrosis. 

To  recapitulate  the  diagnostic  signs  which  point  to  the  death  of  a  portion 
of  the  hody :  Arterial  pulsation  is  absent  in  a  limb  about  to  become  gangrenous ; 
this  sign  cannot  always  be  made  out,  nor  is  ii  positive  when  observed.  Behavior 
of  the  tissues  when  pressed  upon:  Finger  pressure  upon  a  living  portion  of 
the  skin  produces  a  white,  anemic  spot;  the  normal  pink  color  returns  at  once 
when  the  pressure  ceases.  Pressure  upon  a  dead  part  either  leaves  it-  color 
unchanged  or,  if  rendered  paler,  the  color  returns  slowly  and  imperfectly,  if  at 
all.  The  normal  elasticity  of  the  tissues  is  lost,  the  skin  pits  on  pressure,  and 
the  pitting  remains  or  disappears  but  slowly  and  imperfectly.  Puncture  of  a 
living  part  is  followed  by  bleeding,  puncture  or  incision  of  dead  tissue-  is  not, 
or  ;i  little  dark,  venous  hlood  may  appear,  and  if  the  tissues  are  squeezed  dry 
of  their  contained  hlood  the  bleeding  ceases  permanently.  An  abrasion  of  the 
skin  over  a  dead  area  does  not  remain  moist  from  exuded  serum,  hut  rapidly 
dries,  remains  so,  and  in  a  few  hours  turns  brown  in  color.  The  sensibility 
of  a  dead  part  is  lost,  and  the  loss  of  sensibility  does  not  correspond  to  an 
area  of  nerve  distribution,  but  ascends  to  a  more  or  less  uneven  level.  The 
function  of  a  dead  part  is  abolished.  It  is  to  be  borne  in  mind  that  live  forearm 
muscles  may  still,  for  a  time,  move  dead  fingers.  The  temperature  of  a  dead 
limb  is  lower  than  normal,  and  finally  falls  to  that  of  the  surrounding  atmos- 
phere. The  color  of  a  gangrenous  part  is  variable  in  the  early  stages.  Stop- 
page  of  arterial  circulation  renders  the  part  pale;  venous  obstruction,  blue  or 
dark  red  :  later,  mottling  of  the  skin  occurs,  blue  livid  areas  alternating  with 
white  or  dusky  red.  When  gangrene  is  fully  developed  the  changes  are  so 
marked  as  to  be  evident  to  any  eye,  as  already  described. 

Diabetic  Gangrene 

Persons  suffering  from  diabetes  are  peculiarly  susceptible  to  pyogenic  in- 
fections. The  vitality  of  their  tissues  is  lowered,  and  a  considerable  proportion 
of  them  suffer  from  arteriosclerosis  of  the  arteries  of  the  extremities.      While 

gangrene  more  commonly  surs  in  diabetics  beyond  middle  life,  yet  younger 

individual-,  who  except  for  their  diabetes  appear  in  fair  health,  also  Suffer. 
The  occurrence  of  gangrene  is  commonly  associated  with  an  increased  amount 


204 


DISEASES    OF    THE    SOFT    PAETS 


of  sugar  in  the  urine,  and  this  increase  often  goes  on  with  the  spread  of  the 
gangrene  and  diminishes  after  amputation.  Spontaneous  gangrene  of  the  toes 
in  middle  life  leads  us  to  look  for  the  thirst,  polyuria,  and  glycosuria  of 
diabetes. 

Varieties. — Two  forms  of  tissue  necrosis  occur  in  these  cases:  First,  ordi- 
nary gangrene,  usually  of  the  moist  type,  beginning  in  a  toe,  either  spontane- 


Fig.  53. — Diabetic  Gangrene  of  the  Foot  Following  Pott's  Fracture. 
(New  York  Hospital  collection.) 

ously  or  after  a  trifling  injury  such  as  the  paring  of  a  corn  or  a  slight  con- 
tusion. Sometimes  a  chronic  ulcer  of  a  toe  has  existed  for  weeks  or  months, 
slowly  growing  deeper  and  larger  before  the  gangrene  appears.  There  is 
little  tendency  to  limitation  of  the  gangrene  in  these  cases ;  it  is  usually  slowly 
or  rapidly  progressive,  according  to  the  intensity  of  the  associated  pyogenic 
infection  and  the  resisting  power  of  the  individual.      These  patients  often 


GANGRENE  205 

become  septic  ot  pass  into  diabetic  coma,  ; t n«  1  gangrene  of  the  flaps,  even  after 
high  amputation,  is  only  too  common.  A  diminished  quantity  of  sugar,  as 
ili«-  resull  of  diel  or  after  amputation,  is  of  rather  favorable  significance. 

The  second  form  is  rather  ;i  phlegmonous  inflammation  of  the  foot,  begin- 
ning in  some  trifling  wound  or  ulcer,  and  runs  a  rather  insidious  course,  with- 
ou1  much  constitutional  reaction  ot  signs  of  acute  inflammation.  The  wound 
<u-  ulcer  is  found  to  be  slowly  growing  deeper,  and  one  day  ii  i-  noted  thai 
pressure  upon  the  sole  of  the  moderately  swollen  fool  causes  pus  to  escape  from 
the  distanl  openings  An  extensive  burrowing  abscess  with  necrosis  of  the 
connective  tissue  may  thus  be  discovered  whose  extent  was  unexpected.  The 
Bloughing  and  burrowing  usually  proceed  in  spite  of  local  treatment,  and  am* 
putation  offers  the  only  hope  of  survival. 

Dry  Senile  Gangrene 

Dry  senile  gangrene  has  already  been  described.  Senile  gangrene  is  nol 
always  of  this  type;  it  is  often  associated  with  putrefaction  and  more  or  less 
intense  pyogenic  infection,  with  septic  symptoms,  lymphangitis,  abscesses,  etc. 

Gangrene   Due  to  Arteriosclerosis  tx  Early  Middle  Life — Presenile 
Gang  r  e  x  e —  E  r  v  t  hromelalgi  a —  I  x  r  e  r  m  i  tt  ent  Claudicatio  x 

Localized  arteriosclerosis  of  the  arteries  of  the  lower  extremity  occur-  in 
persons  from  thirty  to  fifty  years  of  age.  Tt  is  notably  common  in  natives  of 
certain  parts  of  Russia  and  Poland.  Tt  is  thought  by  some  observers  to  be 
of  syphilitic  origin.  The  symptoms  are  characteristic;  the  individual  suffers 
from  pain  of  a  burning  character  in  the  feet  and  toes  when  walking.  Tn  addi- 
tion, there  are  sensations  of  heat  and  cold,  numbness,  formication  and  other 
paresthesia?,  weakness  of  the  muscles,  ami  lameness.  The  symptoms  disappear 
if  the  patient  keeps  off  his  feet,  and  reappear  when  he  again  walks.  The  toes 
are  often  pale,  sometimes  blue,  swollen,  and  congested.  The  posterior  tibial 
and  dorsalis  pedis  pulses  are  weak  or  absent.  Sooner  or  later  an  ulcer  appears 
on  one  toe  or  along  the  border  of  the  foot,  and  assumes  a  progressive  or  gan- 
grenous character;  a  considerable  part  of  the  foot  may  he  involved.  The  age 
of  the  patient,  the  severe  pain,  and  the  disappearance  of  the  early  symptoms 
when  the  patient  refrains  from  walking  suffice  for  the  diagnosis. 

Gangrene  from   Embolism  and  Thrombosis  of  the  Maix   Artery 

OK     A     I.I  MP. 

Tlie  artery  involved  is  usually  the  femoral  or  the  popliteal;  the  condition 
is  rather  rare;  it  occurs  as  a  complication  of  endocarditis,  in  the  course  of 
acute  infectious  diseases- -  typhoid  fever,  pneumonia,  measles,  scarlel  fever, 
influenza,  etc.:  contusion-  of  the  thorax  and  abdomen  have  been   followed   hv 


206 


DISEASES    OE    THE    SOFT    PAETS 


injury  to  the  abdominal  aorta  and  embolism  or  thrombosis  of  the  iliac  or 
femoral  vessels.  A  number  of  cases  are  on  record  of  gangrene  following 
thrombosis  of  the  aorta  in  acute  infectious  disease.  The  gangrene  has  been 
unilateral  or  symmetrical — i.  e.,  of  both  legs.  If  a  large  artery  is  suddenly 
plugged  by  an  embolus,  severe  pain  is  felt  in  the  entire  limb;  there  is 
muscular  weakness   or   paralyses,   rigidity   of  the   muscles   and   cramps;   the 


Fig.  54. — Moist  Gangrene  of  the  Foot  from  Diabetes.  Recovery  after  amputation  at  the  middle 
of  the  thigh,  with  marked  improvement  in  the  diabetic  symptoms.  (New  York  Hospital,  service 
of  Dr.   F.  W.  Murray.) 


limb  becomes  useless,  cold,  and  pale.  If  collateral  circulation  is  established 
the  limb  gradually  becomes  warmer,  and  circulation  can  be  demonstrated  by 
pressure  on  the  finger-  or  toe-nails.  The  functions  of  the  limb  may  be  grad- 
ually restored  or  ischemic  degeneration  of  the  muscles  and  permanent  atrophy 
of  the  limb  may  follow.     No  collateral  circulation  being  established,  gangrene 


GANGRENE  207 

of  the  <lr\  or  moisl  variety,  according  to  the  absence  or  presence  of  infection, 

result-. 

When  the  thrombosis  "!•  embolism  occurs  in  the  course  "I"  acute  diseases 
where  the  patienl  is  already  very  ill,  the  first  warning  may  be  the  coldness, 
bloodlessness,  and  paralysis  of  one  or  more  extremities.  It  sometimes  happens 
ili.it  the  obliterating  endarteritis  "I"  the  later  stages  of  syphilis  affects  the  larger 
or  smaller  arteries  of  the  extremities,  and  thrombosis  or  obliteration  of  their 
lumena  may  follow  with  the  production  of  gangrene.  Such  gangrene  is  some 
times  symmetrical;  both  hands  or  both  feel  may  be  involved.  Gangrene  due 
in  injury  of  or  pressure  upon  the  main  artery  of  a  limb  may  be  caused  by 
incised  or  punctured  wounds  of  the  artery,  by  contused  wounds,  or  contusions 
of  the  arterial  wall,  [f  gangrene  ensues,  its  causation  will  usually  be  evident. 
Displaced  fragments  of  bone  in  fractures  and  the  pressure  of  dislocated  bones 
may  occlude  the  main  arterial  trunk;  the  cause  of  an  ensuing  gangrene  should 
be  plain  to  the  surgeon.  Pressure  from  tumors  and  foreign  bodies  and  from 
the  effused  blood  of  a  ruptured  aneurism  may  cause  gangrene  <>t'  an  extremity. 
Thrombosis  or  embolism  of  the  main  artery  of  a  limb  may  cause  ^aiurreiie.  In 
the  case  of  the  lower  extremity,  gangr<  ue  is  rare  from  obstruction  of  the  artery 
alone  unless  the  common  iliac  is  involved. 

The  following  case  of  thrombosis  of  the  common  iliac  artery  followed  by 
gangrene  of  the  entire  lower  extremity  is  quoted  as  an  illustration  of  this  rather 
rare  condition.  In  this  case  it  is  not  improbable  that  an  embolism  of  the 
popliteal  was  followed  by  a  thrombosis  extending  upward  to  involve  the  com- 
mon iliac: 

A  young  man.  twenty-eighi  years  of  age,  was  admitted  to  the  hospital  with  the 
following  history:  Very  marked  chronic  alcoholism  for  a  number  of  years;  s\pl i i  1  i < 
three  years  ago.  Of  late  has  been  on  a  prolonged  alcoholic  debauch.  Two  days 
before  admission  lie  was  suddenly  seized  with  complete  loss  of  power  in  the  entire  left 
lower  extremity  and  very  severe  pain,  referred  especially  to  his  leg.  On  admission. 
patient  apathetic,  cerebration  imperfect  and  sluggish.  Temperature  subnormal; 
pulse,  124  and  feeble;  respiration,  28.  Left  lower  extremity  completely  powerless. 
Insensitive  as  far  upward  as  the  knee,  and  coolness  up  to  same  point.  Skin  of 
foot  and  leg;  mottled  reddish-purple  areas  alternating  with  dead  white;  no  evidence 
of  cutaneous  circulation  to  a  point  above  the  knee.  Tn  spite  of  various  efforts,  the 
discoloration,  paleness,  coldness,  and  loss  of  sensibility  continued  to  advance  during 
the  following  days.  Pain  ceased  in  the  limb.  After  three  days  it  was  evident  thai 
the  entire  lower  extremity  was  without  circulation;  no  evidences  o\'  saprophytic  or 
pyogenic  infection.  General  condition  steadily  grew  worse.  Amputation  just  below 
hip-joint.  Wound  entirely  bloodless;  common  femoral  contained  a  thrombus. 
Death  three  days  later  in  coma.  Examination  showed  rigm*  common  iliac  artery 
plugged  by  a  linn  thrombus.     No  definite  lesion  found  to  account  for  the  condition. 


208 


DISEASES    OF   THE    SOET   PARTS 


Gangrene  from  Escharotics 


The  application  of  acids,   alkalis,   and  other  caustics  to  skin  or  mucous 
membranes    causes    local    necrosis.      The    appearances    vary;    sulphuric    acid 

produces  a  greenish-black 
slough.  Nitric  acid  forms 
a  bright  yellow,  later  yel- 
lowish-brown, chemical  com- 
bination with  the  tissues, 
known  as  murexid.  Nitrate 
of  silver  a  superficial  black 
stain.  Chromic  acid  a  green- 
ish-brown slough.  Trichlor- 
acetic acid  a  white  slough. 
The  caustic  alkalis  TCOH 
and  ]STaOH  a  black  slough. 
Zinc  chlorid  a  whitish-gray 
discoloration.  Carbolic  acid 
a  white  slough,  turning 
greenish-black  or  copper- 
colored  later.  (See  Stom- 
ach.) Gangrene  of  fingers 
from  the  improper  use  of 
carbolic-acid  wet  dressings 
by  the  uninformed  laity  is 
very  often  seen  in  city  dis- 
pensaries. So  weak  a  solu- 
tion as  one  per  cent  has 
been  known  to  produce 
sloughing  after  a  day  or 
two.  Five  per  cent  will 
destroy  a  finger  in  a  few 
hours.  Since  carbolic  acid  is  anesthetic,  relief  from  pain  gives  the  patient 
a  sense  of  false  security. 


Fig.  55. — Carbolic-Acid  Gangrene  of  a  Finger.  Patient 
applied  a  dressing  of  crude  undiluted  carbolic  acid  to  his 
finger.  (New  York  Hospital,  Out-Patient  Department,  case 
of  Dr.  Hitzrot.) 


The  Effects  of  Cold  upon  the  Tissues 


Prolonged  exposure  of  the  tissues  to  a  temperature  below  freezing  causes 
gangrene.  The  fingers  and  toes,  the  ears,  tip  of  the  nose,  and  cheeks  are  the 
parts  usually  affected.  Want  of  food,  fatigue,  alcoholism — acute  or  chronic — - 
and  debility  from  any  cause  favor  the  occurrence  of  frostbite.  A  frozen  part 
becomes  pale,  white,  hard,  and  insensitive.  Upon  the  return  of  circulation, 
red,  hot,  tender,  swollen,  and  painful.  A  common  mild  form  of  frostbite 
occurs  in  the  toes  and  fingers  of  improperly  clothed  children  (perniones — chil- 


GANGRENE 


209 


blains).  Upon  returning  to  a  warm  place  after  exposure  to  cold,  the  toes 
lice. me  hot,  swollen,  red,  and  tender,  tntense  itching  is  complained  of,  notably 
at  nighl  in  bed.  In  a  more  severe  form  thrombosis  <>t  the  capillaries  occurs, 
and  a  superficial  ulcer  forms  on  one  or  more  toes.  When  a  pari  is  actually 
frozen  and  is  to  become  gangrenous,  thawing  and  return  of  blood  current  is 
accompanied  by  extravasation  of  blood  through  the  wallsof  the  dead  capillaries; 
the  pari  is  stained  a  deep-blue  color  or  purplish-red;  other  parts  may  remain 
white  and  pale  from  thrombosis  of  the  arteries.     There  is  often  a  good  deal 


Fig.  56. — Cicatricial  Contraction  Following  Extensive  Burn  of  the  Upper  Extremity  wmh 
Complete  Less  of  Function.  A  large  unhealed  area  of  granulation  tissue  occupies  the  region 
of  the  elbow  and  upper  arm.     (New  York  Hospital  collection,  author's  service.) 

of  pain,  but  loss  of  cutaneous  sensibility.    The  phenomena  of  gangrene  follow, 
dry  or  moist,  and  with  <>r  withoul  symptoms  of  sepsis,  according  to  the  presence 

or  absence  of  bacterial  infection. 


15 


210 


DISEASES    OF   THE    SOFT   PAETS 


The  Effects  of  Heat 


The  destructive  effects  of  heat  may  be  produced  by  radiant  heat,  by  flame, 
by  hot  fluids,  or  solids.  The  effects  of  hot  fluids  are  known  as  scalds.  The 
symptoms  are  local  and  general. 

General  Symptoms. — The  severity  of  the  general  symptoms  depends  more 
upon  the  extent  of  cutaneous  surface  involved  than  upon  the  depth  of  the  burn. 
The  charring  of  a  foot  may  not  be  followed  by  serious  constitutional  symptoms. 
A  superficial  burn  of  one  half  of  the  cutaneous  surface  is  usually  attended  by 
fatal  shock.  Shock  is  marked  in  burns  of  the  trunk  and  head.  If  shock  is 
severe,  the  patient  may  pass  at  once  into  a  stupid  or  comatose  state,  from  which 
he  does  not  recover.  In  less  severe  cases  there  is  often  restlessness  and  excite- 
ment. A  chill  may  follow  a  severe  burn,  the  pulse  is  accelerated,  the  tem- 
perature is  usual- 
ly subnormal;  after 
twenty-four  hours 
there  is  commonly 
a  rise  of  tempera- 
ture. Ulceration  of 
the  duodenum  with 
perforation  is  an 
occasional  complica- 
tion, and  acute  ex- 
udative nephritis  in 
some  cases ;  hemo- 
globinuria is  not 
uncommon ;  there 
may  be  vomiting 
and  diarrhea,  some- 
times bloody  diar- 
rhea. The  later 
complications  of  se- 
vere burns  are  sep- 
acute    and    chronic 


Fig.  57. — Extensive  Scarring  and  Deformity  of  the  Arm  Following 
a  Burn.  Condition  greatly  improved  by  a  plastic  operation  and  skin 
grafting.      (Collection  of  Dr.  Charles  McBurney.) 


tic    absorption   from    infection    of    the    burned    surfaces^ 
septicemia,  and  exhaustion. 

Classification. — The  classification  of  burns  suggested  by  Morton  is  here 
given:  First  degree — hyperemia,  erythema,  or  inflammation  of  the  skin  with- 
out vesication ;  no  scar  results.  Second  degree — inflammation  of  the  skin  with 
vesication;  no  scar,  but  staining  from  pigmentation  of  skin  follows.  Third 
degree — in  addition  to  all  seen  in  the  other  degrees,  destruction  of  the  skin 
and  subjacent  tissues  to  varying  degrees  up  to  complete  charring  of  the  parts. 
Much  of  the  subsequent  scarring  and  deformity  results  not  from  the  primary 
injury,  but  from  consecutive  sloughing  or  gangrene,  and  contraction  of  the 
new-formed  tissue  during  and  after  healing. 


GANGRENE 


211 


Symptoms  of  Burns  of  the  First  Degree. —  Pain,  of  a  3tinging  or  burning 
character.  Redness  "I-  skin,  which  disappears  on  pressure  and  returns  when 
the  pressure  is  relieved;  the  redness  persists  for  hours  or  days,  and  desquama- 
tion follows.  Very  extensive  burns,  even  of  this  slight  degree,  may  be  attended 
by  fata]  shock. 

Bums  of  the  Second  Degree. — There  is  intense  burning  pain  in  the  injured 
area.  Large  and  small  blebs  form  on  the  skin  al  once  or  after  several  hours. 
The  blebs  arc  ailed  with 
clear  serum;  after  twenty- 
four  hours  the  serum  may 
become  cloudy.  The  blebs 
are  usually  ruptured  by  ac- 
cident, and  form  a  thin, 
wrinkled     pellicle,     freely 

movable  over  the  moist,  red, 
sensitive,  true  skin  beneath. 
If  the  surface  is  kept  asep- 
tic and  is  not  exposed  to 
mechanical  irritation,  espe- 
cially if  the  blebs  are  mere- 
ly punctured  after  cleansing 
the  surrounding-  skin,  a  new 
cuticle  may  form  without 
any  inflammatory  reaction 
whatever  within  ten  days. 
If  not,  some  swelling,  red- 
ness, heat,  and  a  more  or 
less  copious  discharge  of 
pus  occurs ;  this  discharge 
dries  into  a  scab  or  crust. 
The  new  surface  beneath  is 


red    and    granular    in 


ap- 


Fig.  58. — Deformity  of  Face  AND  Xitk  Two  Years  After 
a  Severe  Burn.     (Collection  of  I>r.  Charles  McBumey.) 


pearance ;  then  gradually 
dries,  and  is  covered  by 
new  epithelium.  Frequent- 
ly a  smooth  pigmented  sur- 
face, at  first  red,  then  brown,  remains;  such  pigmentation  gradually  fades, 
but  may  be  evident  for  many  months.  The  constitutional  effects  depend 
upon  the  size  of  the  burned  surface.  Any  form  of  pyogenic  infection  is 
possible  in  burns  of  this  degree. 

Burns  of  the  Third  Degree. — Under  this  bead  are  included  all  burns  involv- 
ing actual  destruction  of  tissue,  those  causing  the  death  of  a  pari  only  of  the 
thickness  of  the  true  skin,  SO  that  some  of  the  deeper  glandular  organs  lined 
with  epithelium    remain   behind,    as  well    as   those    involving   the   charring    ol 


212  DISEASES    OF   THE    SOET   PAETS 

an  entire  extremity  by  flame  or  molten  metal.  The  appearances  vary  greatly 
in  different  cases.  The  eschars  may  be  pale  yellow  or  white  in  color,  or  black, 
or  brown,  or  ashen  gray,  and  dry  or  moist.  It  is  not  possible  at  once  to  deter- 
mine the  depth  to  which  the  tissues  have  been  deprived  of  their  vitality.  The 
separation  of  the  sloughs  takes  place  very  slowly ;  by  granulation  if  aseptic, 
by  suppuration  if  infected.  It  is  well-nigh  impossible  to  keep  extensive  burns 
of  this  degree  free  from  pyogenic  germs.  The  extensive  granulating  areas  con- 
tract as  they  heal,  and  scars,  often  of  a  disfiguring  or  crippling  character,  follow. 
Thus  the  chin  may  be  drawn  toward  the  sternum ;  the  limbs  may  be  held  in 
a  position  of  flexion;  circular  scars  surrounding  a  limb  may  seriously  inter- 
fere with  its  nutrition;  scars  involving  the  axilla  may  produce,  by  pressure 
upon  the  axillary  vein,  persistent  edema  of  the  entire  upper  extremity. 

Gangrene  from  Injuries  and  Diseases  of  the  jSTervous  System 

Transverse  lesions,  traumatic  or  other,  of  the  spinal  cord — syringomyelia, 
transverse  myelitis — are  frequently  complicated  by  gangrene  of  the  extremities 
- — fingers  and  toes,  and  by  pressure  necrosis  of  those  soft  parts  lying  over 
bony  prominences — sacrum,  os  calcis,  etc.  Paralyzed  limbs,  and  parts  in  which 
the  nervous  sensibilities  are  impaired,  are  predisposed  to  gangrenous  and  ne- 
crotic inflammations  from  two  causes.  The  part  receives  less  blood  than 
normal — i.  e.,  its  nutrition  is  impaired ;  further,  the  diminished  sensibility 
of  the  part  renders  the  individual  unconscious  or  indifferent  to  mechanical 
insults,  such  as  blows,  or  continued  pressure  from  a  wrinkled  stocking,  a 
tight  boot,  etc. 

One  of  the  typical  examples  of  this  condition  is  found  in  tabes  under  the 
name  of  perforating  ulcer  of  the  foot  (mal  perforant).  The  patient  develops 
a  callous  spot  somewhere  on  the  sole  of  the  foot,  on  the  ball  of  the  great  toe, 
or  under  the  first  metatarso-phalangeal  joint.  If  the  thickened  cuticle  is  pared 
away,  it  grows  again  rapidly.  Presently  a  spot  appears  in  the  center  of  the 
callus,  which  looks  as  though  a  drop  of  blood  had  been  extravasated  into  it; 
if  this  is  pared  away  a  small  round  ulcer  is  found  beneath,  from  which  a  little 
thin  discharge  escapes.  If  the  patient  continues  to  walk  upon  the  foot,  the 
ulcer  slowly  increases  in  size  and  depth.  The  ulcer  is  but  slightly  painful, 
and  does  not  give  the  patient  much  inconvenience.  If  he  lies  up  and  does 
not  walk,  the  ulcer  heals,  always  with  the  production  around  it  of  a  large  and 
unnecessary  amount  of  horny  epithelium.  If  he  walks  again,  the  tissue  breaks 
down  and  the  ulcer  reappears.  From  time  to  time  the  raw  surface  becomes 
infected,  and  he  has  an  attack  of  cellulitis  of  the  foot,  more  or  less  severe. 

As  time  goes  on  the  condition  becomes  slowly  worse  until  a  joint  is  opened 
or  a  bone  infected.  Amputation  of  the  toe  is  then  made,  the  wound  heals 
slowly,  but  kindly,  but  when  the  patient  begins  to  walk  again  a  new  ulcer 
forms  in  some  other  place.  The  entire  course  of  the  process  may  extend  over  a 
period  of  many  years. 


GANGRENE 


213 


TfiOPHIC    l'l<   II.' 

A  similar  condition  nol  infrequently  follows  the  division  of  large  nerve 
trunks  in  the  leg^trophic  ulcer.  In  these  cases  the  disturbance  of  nutrition 
in  the  limb  is  more  evident  The  entire  fool  may  be  blue  and  cold,  and  there 
is  a  tendency  to  continued  desquamation.  The  muscles  supplied  by  the  divided 
nerve  are  atrophied.  From  the  pressure  of  the  boot,  or  from  some  trifling 
injury,  au  ulcer  appears 
upon  the  sole  of  the  foot, 
and  grows  larger  and 
deeper.    True  gangrene  is 

more  apt  to  occur  in  these 
cases  than  in  tabes,  and 
considerable     portions    of 

tissue  may  thus  be  'le- 
st roved.  If  the  patient 
ceases  to  walk  the  raw 
surface  may  take  on  a 
healthy  healing  action, 
but  there  is  always  a 
tendency  to  recurrence. 
(See,  also,  Injuries  of 
Special   Nerves.) 

Decubitus  or  Bedsoke 

In  the  course  of  acute 
infectious  diseases,  fol low- 
ing injuries  and  diseases 
of  the  spinal  cord,  and.  in 
fact,  under  all  conditions 
where  extreme  debility 
renders  it  necessary  for 
an  individual  to  lie  in 
bed  upon  his  hack  for  ;i 
long  time,  gangrene  may 
occur  from  impaired  nu- 
trition or  the  continual 
pressure  exerted  upon  the 

tissues  between  the  hour-  of  the  skeleton  and  the  bed.  Beneath  the-  shoulder- 
blades,  along  the  lower  dorsal  spine,  over  the  saeruni,  the  trochanters,  and 
beneath  the  heel  are  the  places  where  this  form  of  gangrene  occurs.  The 
skin  becomes  reddened,  hlehs  form  upon  its  surface,  the  skin  beneath  becomes 
necrotic,  and  an  ulcer  of  a  slowly  or  rapidly  progressive  character  is  formed. 


Fig.  59. 


-Deformity  of  Foot  \m>  Ankle  Following  Severe 
Burns.     (Collection  of  Pr.  C.  N.  Dowd.) 


214 


DISEASES    OF    THE    SOFT    PARTS 


which  continually  extends  until  the  bones  beneath  are  exposed.  The  edges  of 
the  ulcer  are  red  and  inflamed,  the  base  consists  of  yellow  stringy  or  pulpy 
dead  tissue.     If  pyogenic  infection  is  added  the  destruction  of  tissue  may  be 


Fig.  60. — Extensive  Bed-sore  of  the  Sacral  Region  from  Caisson  Disease. 
(New  York  Hospital  Medical  Service.) 

very  rapid,   and  septic  poisoning  may  destroy  the  patient's  life  in  a   short 
time.     (See,  also,  Injuries  of  the  Spinal  Cord.) 

Symmetrical  Gangrene — Raynaud's  Disease 

Symmetrical  gangrene  is  a  rare  disease,  due,  it  is  believed,  to  disturbances 
of  the  vasomotor  centers  in  the  central  nervous  system.  The  disease  is  more 
common  in  women  than  in  men,  and  the  majority  of  cases  occur  before  the 
age  of  thirty  years.  Anemia,  chlorosis,  and  a  neuropathic  constitution  seem 
to  be  predisposing  causes.  The  gangrene  affects  the  fingers  and  toes  of  both 
sides  of  the  body  chiefly,  but  may  attack  the  nose,  the  ears,  or  other  parts  of 
the  body.  The  disease  occurs  in  sharply  marked  attacks.  There  may  be 
but  one  attack  or  several,  rarely  many.  The  attacks  are  sometimes  preceded 
by  nervous  excitement,  sleeplessness,  palpitation  of  the  heart,  etc.  Preceding 
the  occurrence  of  gangrene,  there  are  usually,  but  not  always,  certain  peculiar 
disturbances  in  the  circulation  of  the  affected  part.  These  are,  according  to 
Weiss,  of  three  types:  First,  regional  ischemia;  second,  regional  cyanosis; 
third,  regional  rubor. 

1.  Regional  Ischemia. — Suddenly  and  without  apparent  cause  one  or  more 
fingers  or  toes  become  cold,  white,  shrunken,  bloodless,  and  insensitive.  This 
condition  lasts  for  seconds,  minutes,  or  hours.  The  circulation  then  returns, 
and  only  a  little  numbness  remains. 

2.  Regional  Cyanosis. — The  affected  parts  become  suddenly  dark  red,  then 
blue,  then  black.     They  are  slightly  swollen,  cold  to  the  touch,  there  are  sen- 


GANGRENE  215 

Batione  of  cold  and  pricking.     After  8  longer  <»r  shorter  time  the  circulation 
gradually  returns,  and  tli«'  pari   resumes  it-  normal  appearance. 

:;.  Regional  Rubor. — Suddenly,  as  in  the  other  forms,  the  fingers  or  t< 
become  red,  hot,  and  turgid  with  blood.     The  phenomena  disappear  as  sud- 
denly as  they  came. 

These  several  forms  of  vasomotor  disturbance  may  exist  simultaneously 
mii  different  parts  or  succeed  one  another  in  the  same  part.  There  follow-  an 
attack  of  gangrene.  The  gangrene  may  be  absolutely  ay etrical — i.  e.,  ex- 
actly the  same  situation  on  both  sides  of  the  body,  or  only  partly  bo,  or  there 
may  be  bul  one  spol  of  gangrene.  The  gangrene  usually  occur-  in  the  parts 
previously  affected  with  circulatory  disturbances,  but  may  appear  elsewhere. 
The  pulp  of  the  end  phalanges  of  the  fingers  and  toes  are  the  pine.-  first 
affected  in  the  majority  of  cases.  The  death  of  the  tissues  may  be  confined 
to  the  superficial  layers  of  the  skin,  or  spread  more  deeply  to  involve  the  deeper 
structures,  so  that  an  entire  phalanx  or  the  whole  finger  is  lost.  Dry  gan- 
grene is  the  rule  with  a  sharp  line  of  demarcation.  Moist  gangrene  is  more 
rare.  Pyogenic  infection  is  followed  by  inflammatory  complications.  The 
separation  of  the  dead  parts  is  slow;  two  to  four  months  usually  elapses  from 
the  beginning  of  the  attack  until  the  stump  is  healed. 

Gangrene  of  the  extremities,  following  the  use  of  diseased  rye  for  food, 
chronic  ergotism,  is  at  present  so  rare  that  mere  mention  is  made  of  it  here. 
The  gangrene  of  leprosy  is  associated  with  other  definite  signs  of  the  disease. 

Noma,   ( 'axckmm   okis — Gaxukexe   of  the   Vulva,   tin-;   Umbilicus 

Children  whose  vitality  is  profoundly  depressed  by  acute  or  chronic  dis- 
ease, notably  scarlet  fever  and  measles,  or  who  suffer  from  marasmus  due  to 
neglect,  improper  feeding,  etc.,  suffer  from  gangrene  of  the  mucous  mem- 
brane of  the  mouth  and  of  the  lips,  cheek,  tongue,  jaw,  hard  and  soft  palate, 
and  of  the  external  genitals,  vulva,  and  umbilicus.  The  gangrene  begins  as  a 
small  superficial  slough  upon  the  site  of  some  small  ulcer  or  abrasion  of  the 
skin  or  mucous  membrane;  very  commonly  at  the  red  border  of  the  lip  or 
corner  of  the  mouth.  The  sloughing  process  extends  with  great  rapidity  super- 
ficially, and  deeply  involving  the  entire  thickness  of  the  cheek  in  a  few  day-. 
A  livid  spot  appears  upon  the  skin  surface,  and  rapidly  takes  on  a  gangrenous 
character.  There  is  usually  an  odor  of  putrid  decomposition.  The  dead  parts 
take  on  a  greenish-black  color;  beyond  the  advancing  border  the  tissues  are 
hard,  swollen,  and  infiltrated.  Death  occurs  in  the  majority  of  instances  in 
from  four  days  to  two  weeks.  The  gangrene  may  be  arrested  and  recovery  take 
place.  Deformities  due  to  loss  of  substance  remain — for  example,  cicatricial 
immobility  of  the  jaw. 

The  general  symptoms  are  those  of  grave  constitutional  depression,  often 
without  much  febrile  reaction.  The  children  lie  quietly,  are  stupid,  and  do 
not   seem   to  suffer  much  pain.      Death   takes   place   sometimes   in   coma   or    in 


216  DISEASES    OF   THE    SOFT   PARTS 

collapse  from  septic  poisoning;  sometimes  from  hemorrhage  from  ulceration 
of  an  arterial  trunk  (facial  artery).  Xo  special  microbe  has  been  isolated. 
Cocci  are  found  in  abundance,  both  staphylococci  and  streptococci.  Gangrene 
of  the  vulva  begins  at  the  muco-cutaneous  junction,  and  spreads  as  on  the  face. 


Fig.  61. — Noma,  Gangrene  of  the  Vulva  in  a  Little  Girl.     Death  from  septicemia. 
(New  York  Hospital  collection.) 

The  pubic  region,  perineum,  bladder,  and  rectum  may  be  involved  before 
death.  Gangrene  of  the  umbilicus  in  infants  spreads  through  the  thickness 
of  the  abdominal  wall. 

Hospital  Gaistgrene 

A  progressive  necrosis  of  tissue  occurring  as  a  wound  infection  in  crowded 
hospitals,  military  prisons,  etc.,  in  time  of  war  and  famine  before  the  days 
of  aseptic  wound  treatment.  It  is  at  present  so  rare  that  few  of  the  younger 
generation  of  surgeons  have  ever  seen  it.  The  disease  attacked  recent  or  old 
wounds,  abrasions,  or  ulcerations.  Granulating  wounds  were  most  often 
affected.  K"o  complete  bacteriological  study  of  the  disease  has  been  made.  It 
was  probably  a  mixed  infection  of  pyogenic  and  putrefactive  germs.  The  dis- 
ease was  characterized  by  hemorrhages  into  the  granulation  tissue  covering 
the  wound,  and  by  a  rapid  breaking  down  of  this  tissue  into  a  sloughing 
mass,  often  associated  with  the  evolution  of  stinking  gas  and  putrid  decom- 
position. The  necrotic  process  tended  to  spread  quite  rapidly.  The  consti- 
tutional symptoms  were  those  of  septic  absorption.  A  large  proportion  of 
cases  ended  fatally.  Three  forms  of  the  disease  are  described;  they  often 
merged  one  into  the  other:  (1)  The  croupous  or  diphtheritic  form;  (2)  the 
ulcerating  form;   (3)   the  pulpy  form.      This  last  the  most  serious. 


DELIRIUM    TREMENS  217 

1.  The  Diphtheritic  Form. — The  granulations  became  gray  in  color,  and 
boob  covered  with  a  superficial  necrotic  layer  (diphtheritic  membrane).  Hem- 
orrhages occurred  into  the  substance  of  the  granulations,  and  when  the  false 
membrane  was  removed,  ecchymotic  foci  were  Been  in  a  mass  of  sloughing 
tissue.  The  discharge  from  the  wound  wns  al  firsl  diminished.  Later  it 
became  thin  and  more  abundant.  The  wound  edges  were  swollen,  red,  tender, 
and  undermined. 

2.  The  Ulcerating  Form. —  More  severe  than  the  last.  The  Lesion  was 
Bimilar,  bu1  was  associated  with  putrid  decomposition  of  the  dead  tissues,  and 
a  greater  tendency  to  advance  insidiously  beneath  the  integumenl  with  the 
formation  of  burrowing  sinuses  lined  with  necrotic  tissue.  Constitutional 
depression  was  marked. 

;;.  The  Pulpy  Form. — The  onset  of  the  disease  was  more  sudden,  and  the 
constitutional  symptoms  of  septic  poisoning  more  marked.  The  wound  sur- 
face became  greatly  swollen,  and  was  rapidly  changed  into  a  pulpy  putrefy- 
ing mass.  The  gangrene  was  of  a  distinctly  progressive  type,  involving  all 
the  tissues  of  the  limb.  Joints  were  opened,  bones  became  necrotic,  and  the 
coats  of  arteries  were  destroyed  with  the  occurrence  of  secondary  hemorrhage. 
The  living  tissues  were  in  a  state  of  acute  inflammation  at  the  advancing 
border  of  the  gangrene,  and  were  painful  and  very  sensitive.  The  pro^re-s 
of  the  disease  was  so  rapid  that  a  wound  might  become  several  time-  it-  original 
size  in  a  day  or  two.  The  general  symptoms  were  those  id'  septicemia;  repeated 
chills  occurred  in  many  cases;  the  fever  was  continuous  or  remittent;  the 
temperature  was  often  very  high  (10-i°-106°   F.). 

DELIRIUM    TREMENS 

Delirium  tremens  is  an  acute  form  of  delirium  which  occurs  in  ] per- 
sons who  habitually  drink  an  excessive  quantity  of  alcohol.  It  may  occur 
at  any  time  of  life.  An  attack  may  follow:  (1)  Sudden  abstinence 
from  alcohol;  (2)  a  prolonged  alcoholic  debauch;  ( .'!  )  acute  diseases  (pneu- 
monia, erysipelas,  influenza,  etc.);  (4)  an  accidental  injury  or  a  surgical 
operation. 

The  prodromal  stage  after  an  injury  may  be  very  short,  and  may  last  only 
twenty-four  or  forty-eight  hours.  It  is,  therefore,  wise  when  a  patient  pre- 
sents himself  with  the  intention  of  having  a  surgical  operation  performed 
and  shows  marked  evidences  of  a  chronic  alcoholic  habit  to  postpone  the  oper- 
ation, if  possible,  until  he  has  been  without  alcohol  for  a  fortnight  or  more. 
lie  must  be  kept  quiet  in  bed  during  this  lime  and  receive  appropriate  treat- 
ment. As  occurring  after  injuries  and  surgical  operations  delirium  tremens 
is  a  very  serious  disease.  It  is  notably  common  after  fractures  oi  the  lei:  and 
thigh,  and  the  mortality  in  these  conditions  is  high.  It  is  well  recognized  by 
all  surgeons  that  chronic  alcoholics  are  bad  surgical  risks.  Delirium  tremens 
may  be  described  as  running  its  course   in   three  stages:    First,    a    prodromal 


218  DISEASES    OE    THE    SOFT   PAETS 

stage^  lasting  from  a  day  to  several  days;  second,  the  stage  of  active  delirium, 
lasting  from  two  to  ten  days,  and  ending  in  death ;  or  in  a  third  stage,  that 
of  convalescence. 

The  -prodromal  stage  is  characterized  by  restlessness,  sleeplessness,  nerv- 
ous irritability,  and  coarse  muscular  tremor  (easily  observed  by  asking  the 
patient  to  protrude  his  tongue  and  hold  out  his  hand  with  the  fingers  ex- 
tended). The  patient  sweats  readily,  notably  upon  the  forehead.  He  is  very 
talkative. 

After  hours,  or  a  day  or  more,  the  symptoms  of  active  delirium  come  on, 
sometimes  gradually,  sometimes  suddenly.  He  begins  to  have  hallucinations 
of  sight  and  hearing;  these  are  nearly  always  of  a  disagreeable  character; 
numerous  animals  are  crawling  over  him  or  trying  to  bite  him — rats,  mice, 
snakes,  monkeys,  etc. ;  "  little  black  men  are  winding  him  up  in  endless  coils 
of  wire,  which  he  continually  strives  to  unwind  (stereotyped  movements)." 
A  large  number  of  persons  are  conspiring  against  or  are  trying  to  do  him  harm ; 
an  angry  crowd  is  cursing  him  outside  the  window.  This  multitudinous  char- 
acter of  these  delirious  concepts  is  characteristic.  He  is  never  quiet  for  a 
moment;  an  extreme  degree  of  motor  excitement  exists;  he  moves  about  in 
bed  and  pulls  at  the  bedclothes  or  tries  to  get  up.  Sometimes,  he  is  seized 
with  maniacal  frenzy  and  strives,  by  rushing  aimlessly  about,  to  escape  the 
horrid  beings  which  continually  molest  him;  such  is  the  cause  of  the  fatal 
leaps  from  windows,  etc.,  in  these  cases.  Homicidal  mania  is  much 
more  rare. 

There  may  be  a  rise  of  temperature,  even  in  uncomplicated  cases.  If  the 
fever  is  high — 103°— 104°  ■  F. — it  is  of  unfavorable  significance.  In  many 
cases  the  temperature  is  not  elevated.  The  pulse  is  rapid  and  compressible. 
The  skin  is  cool,  often  bathed  in  sweat;  cyanosis  of  the  extremities  is  present 
in  bad  cases.  The  tongue  is  coated,  white  at  first,  later  it  may  become  dry 
and  brown.  Constipation  is  the  rule ;  rarely  profuse  diarrhea.  The  tendon 
reflexes  are  exaggerated.  There  is  frequently  marked  insensibility  to  pain. 
The  urine  is  diminished  in  quantity,  of  a  high  specific  gravity,  and  frequently 
contains  albumen.  General  clonic  convulsions  and  epileptiform  seizures  occur 
in  some  of  the  bad  cases. 

The  condition  described  continues  for  a  variable  time,  two  to  ten  days, 
and  ends,  in  bad  cases,  in  exhaustion  and  death.  The  patients  become  coma- 
tose, or  suddenly  go  into  a  state  of  collapse,  or  die  from  some  complication — 
nephritis  or  pneumonia,  for  example.  Some  of  them  pass  into  an  apathetic 
condition,  gradually  merging  into  coma;  in  this  state  they  may  live  many 
days.  At  the  autopsy,  in  addition  to  the  other  lesions  of  chronic  alcoholism, 
the  meninges  of  the  brain  are  found  thickened  and  edematous  (wet  brain). 
If  the  patient  is  to  recover,  he  falls  into  a  deep  sleep  lasting  many  hours 
and  awakes  convalescent.  The  acute  nervous  disturbances  and  hallucinations 
have  disappeared,  and  beyond  some  confusion  of  mind  and  a  feeling  of 
"  empty-headedness,"   lasting  for  hours   or   days,   these   patients  suffer  only 


ORTHOFORM    DERMATITIS  219 

from  a  variable  degree  of  prostration.  In  some  casee  one  or  more  delusions 
may  persisl  for  some  days;  rarely  the  attack  is  the  1  .< -ir i 1 1 1 1 i 1 1 ir  of  a  chronic 
insanity. 

IODOFORM    POISONING 

The  very  restricted  use  of  iodoform  as  a  surgical  dressing  for  wounds  at 
the  present  time  renders  the  occurrence  of  poisoning  by  this  drug  quite  rare. 
Iodoform  is  capable  of  causing  ji  violent  and  obstinate  dermatitis  when  used 
as  a  powder  or  in  an  ointmenl  upon  the  skin.  In  former  days  I  saw  many 
cases  of  this  kind.  The  lesion  was  more  frequent  upon  the  hands  thai  else- 
where, luit  often  spread  far  beyond  the  limits  of  the  area  to  which  the  iodo- 
form   was    applied.       Willi    the   subjective    symptoms    of    burning    and    itching, 

the  skin  of  the  fingers  and  hand  would  exhibit  diffuse  swelling  and  redness, 
followed  by  vesication.  The  early  limitation  of  the  eruption  to  a  geometrical 
ana  corresponding  to  the  size  and  shape  of  the  iodoform  dressing  served  to  dis- 
tinguish the  condition  from  septic  cellulitis.  After  the  redness  had  existed 
for  several  days  the  horny  layer  of  the  skin  became  sodden  and  white,  and 
later  separated  as  a  east  of  an  entire  finder  or  several  fingers,  leaving  a  moist, 
weeping,  tender,  red  surface  of  true  skin  beneath.  Much  pain  was  complained 
of,  and  the  lesion  was  slow  to  heal  and  prone  to  relapses  from  the  applica- 
tion of  supposedly  nonirritating  dressings.  General  intoxication  from  the 
absorption  of  iodoform  through  recenl  wound  surfaces  was  formerly  not 
very  uncommon.  The  symptoms  of  iodoform  poisoning  were  thus  grouped 
by  Schede: 

1.  High  Fever.  2.  Fever  with  gastrointestinal  irritation,  rapid  pulse,  and  de- 
pression of  spirits.  3.  Very  rapid  compressible  pulse  without  fever.  This  is  a 
dangerous  form.  4.  Very  rapid  pulse  and  very  high  fever.  5.  Great  depression, 
collapse,  early  death.  6.  Cerebral  symptoms  somewhat  resembling  those  indicating 
meningitis.     (McBurney.) 

In  most  cases  when  iodoform  has  been  used  at  all  extensively  upon  a  wound, 
whether  the  patient  is  suffering  from  iodoform  poisoning  or  not,  Lodin  may 
be  detected  in  the  urine  by  shaking  the  urine  in  a  test-tube  with  a  little  com- 
mercial nitric  acid  and  chloroform.  After  slinking,  the  chloroform  settles  to 
the  bottom  of  the  test-tube,  and  if  iodin  is  presenl  acquires  a  purple  color. 
The  starch  test  for  iodin  may  be  u^vi]  in  the  following  way:  A  little  urine 
is  added  to  a  dilute  solution  of  cooked  starch.  The  addition  of  a  few  drops  of 
commercial  nitric  acid  causes  in  the  presence  of  iodin  the  characteristic  deep- 
blue  coloration. 

ORTHOFORM    DERMATITIS 

A  peculiar  itching  erythema,  together  with  very  marked  edema  of  the  skin, 
may  follow  the  local  use  of  orthoform  as  a  dusting  powder  or  dressing  for 


220  DISEASES    OF   THE    SOFT   PAETS 

wounds.  When  used  upon  the  genitals,  the  edema  of  the  prepuce  and  scrotum 
may  reach  alarming  proportions,  and  in  the  absence  of  a  correct  interpreta- 
tion of  the  condition  may  lead  to  confusion  in  diagnosis.  The  symptoms  of 
burning  and  itching  are  marked;  true  pain  is  absent.  The  skin  is  moderately 
reddened.  If  the  use  of  the  drug  is  stopped  the  edema  slowly  subsides  after 
a  number  of  days.     Vesication  is  present  in  some  cases. 


CHAPTER    VII 

TUMORS 

DEFINITION    AND    CLASSIFICATION 

Tin',  diagnosis  of  tumors  is  one  of  the  mosl  important  and  interesting 
portions  of  a  proper  medical  training.  The  family  physician  should  be  as  well 
informed  in  this  matter  as  the  surgeon,  because  to  the  former  are  exhibited 
the  often  Bmall  and  apparently  innocent  new  growths  of  his  patients  a1  a  time 
when  a  correct  diagnosis,  followed  by  prompt  treatment,  will  in  many  instances 
resull  in  permanent  cure,  while  an  expectant  altitude  will  only  too  often  mean 
delay  until  such  a  tardy  moment  that  treatment  is  unavailing.  No  entirely 
satisfactory  definition  of  the  word  tumor,  as  used  to  designate  pathological 
new  growths,  can  lie  given;  the  simple  translation  into  English — a  swelling — 
does  not  suffice,  since  many  swellings  have  no  relation  whatever  to  new  growths. 
We  are,  moreover,  entirely  in  the  dark  in  regard  to  the  causation  of  tumors  in 
general,  and  in  regard  to  certain  kinds  of  tumors  we  do  not,  as  yet,  certainly 
know  whether  they  are  parasitic  diseases  ot  not. 

Various  definitions  have  keen  proposed  by  pathologists  for  the  word  tumor. 
According  to  Cornil  and  Ranvier,  a  tumor  is  "  any  new  growth  which  possesses 
the  tendency  to  persist  or  to  grow."  According  to  Luke,  "  a  tumor  is  an  in- 
crease in  volume  through  the  formation  of  new  tissue  which  fulfills  no  physi- 
ological purpose."  According  to  Billroth,  "  a  tumor  is  a  new  growth  which 
occurs  from  other  causes  than  the  inflammatory  new  growths,  and  which  shows 
a  growth  which  is  nol  limited  by  am  definite  boundarv,  hut  which  tend-  to 
grow  indefinitely."  Virchow  did  not  attempt  a  definition  of  the  word 
t  innor. 

The  diagnosis  of  tumors  naturally  falls  under  two  heads:  the  clinical  diag- 
nosis and  the  microscopical  diagnosis.  Clinically,  we  distinguish  two  groups 
of  tumors:  the  benign  and  the  malignant.  Microscopically,  tumors  are  divided 
according  to  the  character  of  the  tissue  composing  them:  broadly,  into  epi- 
thelial tumors  and  connective-tissue  tumor-,  or,  morphologically,  tumors  may 
he  (dassitied  according  to  the  type  of  embryonal  tissue  in  which  they  originate. 
Thus  the  epithelial  tumors  are  derived  from  the  outermost  and  innermost  em- 
bryonal layers:  ectoderm  or  entoderm,  the  epiblast  and  the  hypoblast.  The 
connective-tissue  tumors,  on  the  other  hand,  are  derived  from  the  middle  layer: 
the  mesoblast,  mesoderm. 

22] 


222  TUMOKS 

Commonly,  tumors  are  still  further  classified,  according  to  the  particular 
type  of  tissue  which  they  contain,  into  a  number  of  different  classes,  to  be 
spoken  of  later.  Some  of  the  epithelial  tumors  are  benign  and  some  are  malig- 
nant, and  the  same  is  true  of  the  connective-tissue  tumors;  and  in  regard  to 
the  individual  tumor,  this  question  of  benignancy  or  malignancy  is  of  far 
greater  consequence  for  the  patient  and  the  physician  than  is  the  par- 
ticular kind  of  tissue  of  which  the  tumor  is  composed.  In  not  a  few 
instances,  indeed,  it  is  difficult,  and  even  impossible,  to  classify  a  tumor 
according  to  the  character  and  arrangement  of  the  tissues  composing  it,  for 
certain  tumors  consist  of  many  kinds  of  tissue,  variously  arranged,  and  the 
character  and  arrangement  may  change  markedly  with  the  growth  of  the 
tumor.  Thus,  many  benign  tumors  may  after  a  time  acquire  a  malignant 
character,  and,  rarely,  a  malignant  tumor  may  become  less  malignant  or 
even  benign. 

A  benign  tumor  is  one  which  has  no  unfavorable  influence  per  se  upon  the 
general  health  of  an  individual.  It  may  produce  disagreeable,  and  even  fatal, 
symptoms  on  account  of  its  size  or  situation;  by  pressure,  for  example,  on 
important  organs,  as,  in  the  interior  of  the  skull,  upon  the  brain,  or,  in  the 
neck,  by  pressure  upon  the  trachea ;  or,  on  the  other  hand,  it  may  produce 
ugly  deformities  or  may  interfere  mechanically  with  locomotion.  Another 
important  character  of  benign  tumors  is  that,  once  removed,  they  do  not 
return. 

The  malignant  tumors,  on  the  other  hand,  possess  what  may  be  fairly  called 
an  infectious  character ;  that  is  to  say,  they  not  only  increase  in  size,  but  sooner 
or  later  infect  the  entire  organism.  Their  growth  takes  place  not  only  by  an 
increase  in  volume,  but  by  growing  into — infiltrating,  as  it  is  called — and 
destroying  the  surrounding  tissues,  without  regard  to  their  character.  They 
also  spread  in  another  way ;  the  tumor  cells  enter  the  lymphatic  circulation, 
are  carried  to  the  neighboring  lymphatic  glands,  and  there  produce  new  tumors 
possessing  all  the  malignant  characters  of  the  primary  growth.  This  is  espe- 
cially true  of  the  carcinomata.  Moreover,  sooner  or  later  the  tumor  cells  enter 
the  blood  current,  and  lodge  in  distant  organs ;  thus  secondary  tumors  are 
produced  in  the  liver,  in  the  lungs,  in  the  bones,  etc.  When  a  malignant  tumor 
has  thus  been  disseminated  throughout  the  body,  the  health  of  the  individual 
is  profoundly  affected.  He  becomes  pale,  weak,  and  anemic,  and  falls  into 
the  condition  known  as  cancerous  cachexia. 

Another  marked  tendency  of  malignant  tumors  is  to  return  after  they  have 
been  removed  by  operation,  either  in  the  scar  or  close  by  in  the  neighboring 
tissues  (local  recurrence)  ;  regional  recurrence  when  the  new  tumors  appear 
in  the  neighboring  lymph  nodes,  or  when  their  anatomical  situation  corresponds 
with  site  and  direction  of  the  lymph  channels.  When  the  new  tumors  appear 
in  distant  organs  and  the  tumor  elements  have  been  transported,  presumably  by 
the  blood  current,  we  speak  of  them  as  metastatic  tumors,  or  metastases.  It 
often  happens  that  the  tissue  of  a  malignant  tumor  does  not  possess  the  vitality 


OCCURRENCE 

of  ili«'  normal  structures,  and  these  turners  nil  show  a  decided  tendency  to  de 
generative  changes  of  one  sorl  or  another.  This  results  in  hemorrhages  into 
the  substance  of  the  tumor,  to  areas  of  necrosis  and  fatty  degeneration,  and, 
finally,  to  ulceration  of  the  skin  covering  the  tumor;  this  ulceration  sometimes 
takes  "ii  a  gangrenous  character;  thus  blood-vessels  may  be  opened,  and  dan- 
gerous, or  even  fatal,  bleeding  may  occur.  Putrid  and  pyogenic  infections  a<l<l 
the  symptoms  of  septic  intoxication,  usually  in  a  rather  chronic  form. 

OCCURRENCE 

In  the  diagnosis  of  tumors  a  hereditary  tendency  seldom  plays  an  impor- 
tant role;  it  sometimes  happens  thai  successive  generations  of  a  family  suffer 
from  cancerous  disease,  hut  such  occurrences  are  the  exception.  Nor  has  a 
hereditary  predisposition  any  important  bearing  upon  the  diagnosis  of  benign 
new  growths.  The  carcinomata  develop  during  middle  life  or  later  in  a  large 
proportion  of  cases;  a  certain  number  do,  however,  occur  in  young  persons,  but 
not  before  puberty,  it  is  believed.  Of  seventy  cases  of  cancer  of  the  breast 
coming  under  my  own  observation,  the  average  age  was  fifty  years;  the  oldest 
patient  was  aged  seventy-nine,  the  youngest  thirty-one;  twelve  of  the  cases  wen- 
less  than  forty  years  of  age.  The  sarcomata  may  appear  at  any  time  of  life; 
sometime-  they  are  congenital,  or  appear  in  infancy,  and  a  considerable  pro- 
portion of  them  occur  during  the  period  of  adolescence  and  early  adult  life; 
they  are  rather  rare  in  old  age. 

.Malignant  tumors  occasionally  follow  injury,  and  they  are  especially  likely 
to  occur  upon  parts  of  the  body  subjected  to  mechanical  irritation,  notably  if 
such  irritation  is  kept  up  over  a  period  of  years.  This  is  especially  true  of 
the  epitheliomata  and  carcinomata.  The  lips,  tongue,  pharynx,  lower  portion 
of  the  esophagus,  pyloric  end  of  the  stomach,  ileocecal  junction,  and  the  anus 
are  subjected  to  more  mechanical  irritation  than  other  parts  of  the  alimentary 
canal,  and  it  is  in  these  situations  that  cancer  is  prone  to  occur.  Out  of  forty 
cases  of  cancer  of  the  lower  lip  which  have  come  under  my  observation,  all  were 
males,  and  all  but  one  had  habitually  smoked  a  pipe,  and  the  cancer  first 
appeared  upon  the  part  where  the  pipe  rested.  Those  who  work  with  paraffin 
acquire  a  chronic  dermatitis  of  the  skin  of  the  hands,  sometimes  followed 
by  epithelioma.  Chimney-sweeper's  cancer  of  the  scrotum  has  long  been 
known.  In  recent  years  it  has  been  noted  in  numerous  instances  that  the 
chronic  dermatitis  occurring  upon  the  hands  of  those  who  work  with  the 
X-rays  has  been  followed  by  epithelioma.  Ancient  scars  and  chronic  ulcera- 
tions sometimes  become  the  seat  of  epithelioma.  The  sarcomata  are  known 
to  follow  injuries  of  bone  in  a  certain  proportion  of  cases.  Dennis  relates 
seven  instances  of  this  kind  in  which  sarcoma  followed  fractures.  Out  of 
seventy  cases  of  sarcoma  collected  by  Coley,  forty  appeared  to  have  a  trau- 
matic origin. 


224  TUMORS 

DIAGNOSIS 

In  the  diagnosis  of  tumors  it  is  necessary  to  exclude,  in  many  instances, 
certain  inflammatory  processes,  notably  syphilis,  tuberculosis,  and  actinomy- 
cosis; encapsulated  exudates  of  various  kinds,  such  as  chronic  abscesses  and 
unabsorbed  effusions  of  blood ;  certain  parasitic  diseases — echinococcus  and 
cysticercus ;  chronic  inflammations  with  condensation  of  tissue,  such  as  chronic 
mastitis,  periostitis,  ruptured  aneurisms,  etc.  Syphilis  is  to  be  eliminated  by 
the  administration  of  mercury  and  of  large  doses  of  iodid  of  potassium,  con- 
tinued for  a  number  of  weeks ;  tuberculosis,  by  the  recognition  of  tubercle  tissue 
or  bacilli  in  scrapings  from  a  raw  surface,  and  the  inoculation  of  guinea  pigs, 
and  by  the  use  of  an  aspirating  needle;  actinomycosis,  by  the  recognition  of 
the  characteristic  granules  in  scrapings  and  discharges.  In  many  instances 
of  doubt  the  aspirating  needle  furnishes  very  valuable  information,  not  only 
as  to  the  character  of  the  fluid  withdrawn  from  a  cavity,  but  also  as  to  the 
consistence  of  the  mass — bony,  calcareous,  partly  solid,  etc.  The  needle  may 
penetrate  a  thin  lamella  of  bone  and  sink  into  a  mass  of  soft  tissue  within  its 
interior,  thus  demonstrating  a  distinctive  process  in  the  medulla,  etc. 

The  history  of  a  tumor  often  furnishes  valuable  diagnostic  aid.  A  tumor 
which  has  existed  a  long  time  and  has  grown  slowly  and  steadily  is  probably 
benign.  If,  after  a  tumor  has  grown  slowly  for  a  long  period,  it  suddenly 
takes  on  a  rapid  growth,  it  has  probably  become  malignant.  Kapid  growth 
always  creates  a  suspicion  of  malignancy.  Pregnancy  and  menstruation  cause 
malignant  tumors  to  grow  more  rapidly;  they  may  have  a  similar  effect  upon 
benign  tumors.  A  characteristic  of  certain  soft  sarcomata  is  that  considerable 
hemorrhages  may  take  place  into  the  interior  of  the  tumor  from  time  to  time. 
Thus  a  very  sudden  increase  in  the  size  of  the  tumor  occurs ;  the  sign  is  of  bad 
omen.  A  ruptured  aneurism  may  produce  a  condition  not  very  unlike  this,  and 
in  certain  cases  may  lead  to  an  error  in  diagnosis. 

For  example,  a  man  was  admitted  to  the  hospital  and  came  under  my  care ; 
he  had  suffered  for  several  months  from  symptoms  indicating  obstruction  of 
the  left  ureter ;  his  urine  contained  pus.  The  left  loin  was  occupied  by  a  large 
tumor ;  from  its  situation  it  was  thought  to  be  connected  with  the  kidney.  The 
man  stated  that  the  tumor  had  within  the  past  few  days  greatly  increased  in 
size.  A  probable  diagnosis  of  hemorrhage  into  a  sarcoma  of  the  kidney  was 
made.  An  incision  in  the  loin  showed  that  the  tumor  was  a  large  blood  clot 
in  the  retroperitoneal  tissue.  The  source  of  the  blood  clot  was  a  ruptured 
aneurism  of  the  abdominal  aorta. 

Pain. — The  pain  produced  by  tumors  varies  greatly  both  in  the  benign  and 
malignant  forms.  Benign  tumors  may  be  very  painful  when  they  press  upon 
or  involve  nerve  trunks.  Thus  the  neuro-fibromata,  fibrous  tumors  arising 
from  the  sheath  of  a  nerve,  are  often  exceedingly  painful.  Malignant  tumors 
are  often  not  at  all  painful  while  they  are  small.  The  sarcomata  may  grow  to 
a  large  size,  and  even  destroy  life,  with  but  little  pain.     Carcinomata  usually 


DIAGNOSIS  225 

become  painful  after  :i  time;  the  pain  is  described  as  of  a  lancinating  character. 
A  sense  of  tightness  or  drawing  i-  often  complained  of  in  cases  of  advanced 
cancer  of  the  breast.     Winn  a  malignanl  tumor  has  broken  down  ;m<l  ulcerated, 

there  is  usually  a  g I  deal  of  pain.     When  carcinoma  has  involved  the  axillary 

Is  :iinl  brachial  plexus  of  nerves  and  has  caused  hard  edema  of  the  arm, 
the  sufferings  of  the  patienl  are  constanl  and  agonizing. 

In  examining  an  individual  tumor,  a  number  of  physical  facts  are  to  be 
observed.  The  situation  and  point  of  origin  of  the  growth  are  of  interest. 
The  type  of  tissue  found  in  a  tumor  resembles  more  or  less  closely  the  tissue 
from  which  it  originated.  Thus,  a  tumor  growing  in  the  subcutaneous  tissue 
will  be  a  fibroma  or  a  lipoma;  a  tumor  growing  from  hone  will  contain  bony 
or  cartilaginous  tissue,  or  may  be  a  sarcoma.  A  tumor  of  a  glandular  organ 
will  often  he  an  adenoma,  an  adeno-fibroma,  a  cyst,  or  a  carcinoma.     The  aize 

of  a  tu r  may  give  some  hint  as  to  its  character.     If  it  he  very  large,  of  alow 

growth,  ami  the  general  health  of  the  patient  remain-  good,  it  is  almosl  eer- 
tainly  benign.  It'  large  ami  of  rapid  growth,  it  i-  probably  malignant;  an 
accompanying  cachexia  will  usually  render  the  diagnosis  of  malignant  disease 
certain. 

Number. — The  fibromata  and  lipomata  and,  notably,  fibroma  mollnscum, 
of  the  skin  are  often  multiple.  Malignant  tumors  in  their  early  stages  are 
single,  with  rare  exceptions;  later  on  they  become  multiple.  The  two  pictures 
are,  however,  dissimilar.  The  multiple  benign  tumors  will  usually  be,  roughly, 
of  the  same  age  and  size;  of  the  multiple  malignant  tumor-,  the  primary  growth 
will  lie  older,  the  secondary  younger,  and  either  large  or  small.  The  consistence 
of  a  tumor  may  often  be  an  important  element  in  the  diagnosis.  Nothing  is 
more  characteristic  than  the  soft,  elastic,  semifluctuating  consistence  of  a  lipoma 
or  the  stony  hardness  of  a  scirrhous  carcinoma  of  the  breast.  A  tumor  which 
i-  hard  in  one  place,  soft  in  another,  is  composed  of  several  kinds  of  tissue  or 
has  undergone  some  form  of  degeneration;  such  a  condition  is  not  infrequent 
in  sarcomata  and  in  tumors  of  the  parotid  gland  and  testis. 

Relation  of  the  Tumor  to  the  Surrounding  Parts. — Benign  tumors  have  a 
connective-tissue  capsule  hut  loosely  attached  to  the  surrounding  tissues;  hence, 
they  are  movable  or  the  tissues  can  he  moved  over  them.  Some  sarcomata  have 
also  a  capsule  in  their  early  stage  of  growth,  ami  may  he  movable;  later  they 
often  infiltrate  and  cease  to  he  go.  Carcinomata  are  always  firmly  attached  to 
the  surrounding  parts;  they  have  no  capsule,  they  infiltrate  the  surrounding 
tissues  from  the  start,  and  often  have  no  sharply  marked  boundaries.  Benign 
tumors  usually  leave  the  -kin  intact  and  healthy:  it  may  lie  thinned  and 
stretched,  and,  if  subjected  to  pressure  or  mechanical  irritation,  superficial 
necrosis  may  occur,  hut  the  cause  is  manifestly  a  mechanical  one  from  without. 

Malignant  Tumors. — Carcinoma  especially,  and  sarcoma  in  its  later  stages, 
infiltrate  and  involve  the  skin,  causing  often  ulceration  of  a  progressive  char- 
acter. Before  the  skin  is  actually  involved  ii  i-  pale  and  glossy;  dilated  cutane- 
ous veins  are  often  visible.  But  rapidly  growing,  malignant  tumors  may  pro- 
16 


226  TTT1I0KS 

duce  marked  redness  of  the  skin — so  marked  that  such  tumors  may  be  mistaken 
for  an  acute  inflammatory  process.  Benign  tumors  do  not  infect  the  lymphatic 
glands.  If  a  benign  tumor  becomes  infected  with  pyogenic  germs,  the  lymph 
glands  will  sometimes  enlarge ;  they  will  also  be  tender  and  painful.  Carci- 
noma infects  the  lymph  nodes  early  in  the  disease ;  the  enlargements  are  hard, 
insensitive,  and  painless.  Sarcoma  causes  infection  of  lymph  glands  less  often 
than  carcinoma,  and  the  infection  takes  place  late  in  the  disease.  The  glands 
become  enlarged,  but  not  hard.  As  is  the  case  with  carcinoma,  they  are  pain- 
less and  insensitive.  One  of  the  peculiarities  of  certain  forms  of  carcinoma 
is  the  production  of  scar  tissue;  the  contraction  of  this  fibrous  stroma  of  the 
tumor  causes  puckering  and  pitting  of  the  overlying  skin.  The  characteristic 
retraction  of  the  nipple  in  carcinoma  of  the  breast  is  a  good  example  of  this 
effect;  it  is  a  sign  of  a  good  deal  of  value,  even  early  in  the  disease.  The 
ulceration  of  malignant  tumors  is  not  confined  to  the  skin.  There  is  a  tendency 
to  degenerative  changes  in  the  entire  tumor  mass,  and  the  skin  once  broken, 
the  degenerative  process  often  advances  rapidly.  Thus  serious  and  even  fatal 
bleeding  may  take  place  from  the  raw  surface  of  the  ulcer  from  eroded  vessels. 
Septic  infection  and  putrid  decomposition  of  broken-down  tumor  tissue  is 
exceedingly  common  in  the  later  stages  of  carcinoma. 

Macroscopic  Appearances. — After  a  tumor  is  removed  from  the  body  an  in- 
spection of  its  cut  surface  gives  valuable  aid  in  diagnosis.  A  glistening  white 
cut  surface,  dry  and  of  rather  firm  consistence,  is  characteristic  of  fibroma.  A 
sharply  marked  boundary,  moderately  firm,  even  consistence,  pink  or  grayish- 
pink  in  color,  surface  moist,  but  not  juicy,  and  a  lobulated  structure — adenoma, 
adeno-fibroma.  The  drier  the  cut  surface  of  a  tumor  and  th.e  more  distinctly 
it  is  encapsulated  the  more  likely  that  it  is  benign.  The  only  benign  tumors 
having  a  juicy  cut  surface  are  myxoma  and  certain  fibromata.  Inequalities  in 
character  of  the  surface,  alternating  soft  and  hard  spots  here  and  there,  are 
suggestive  of  malignancy. 

The  carcinomata  often  permit  one  to  see  their  alveolar  structure  plainly 
with  the  naked  eye.  Upon  squeezing  the  tumor  or  scraping  its  cut  surface 
with  a  knife,  a  milky,  turbid  fluid  or  semifluid  material  exudes — the  so-called 
"  cancer  juice,"  composed  of  masses  of  epithelial  cells  usually  in  a  state  of 
fatty  degeneration.  From  the  surface  of  epitheliomata  one  can  often  express 
the  little  white  spherical  masses  of  concentrically  arranged  epithelial  cells 
known  as  epithelial  "  pearls."  The  malignant  tumors,  as  already  stated,  do 
not  possess  sharp  boundaries,  but  send  prolongations  into  or  infiltrate  the  sur- 
rounding tissues.  Sarcomata  vary  so  much  that  no  single  description  suffices 
for  a  typical  picture  of  their  appearances.  In  their  earlier  stages  they  may 
possess  a  capsule.  The  cut  surface  of  a  fibro-sarcoma  varies  but  little  from 
that  of  a  fibroma.  The  round-celled  variety  has  a  homogeneous  white  or  pale- 
gray  surface;  a  milky  juice  exudes  on  pressure.  The  tissue  resembles  bone 
marrow,  sometimes  brain,  in  appearance.  The  tumor  is  usually  soft  and  friable. 
Hemorrhages  and  all  forms  of  degeneration  are  common  in  both  round-celled 


DIAGNOSIS    OF   THE    DIFFERENT    KINDS    OF   TUMORS 


227 


varieties  "I  sarcoma.  The  giant-called  sarcoma,  one  of  the  less  malignant 
varieties,  ;i  common  tumor  of  the  lower  jaw  (epulis),  is  ;i  firm,  hard  tumor 
not  differing  much  in  gross  appearance  from  fibroma.  The  formation  of  cystic 
rarities  containing  greenish,  brownish,  blood-stained  fluid,  or  actual  blood,  i- 
\n\  common  in  rapidly  growing  sarcomata.  Other  macroscopic  appearances 
of  tumors  "ii  section  will  be  found  under  appropriate  headings. 

THE    DIAGNOSIS    OF    THE    DIFFERENT    KINDS    OF    TUMORS 

(  '<  >  \  .\  i:<  IT  I  V  E-T 1 SS I "  E    T  QMOBS 

Lipoma — Fatty  Tumor. — The  lipomata  form  large  and  small,  rounded  or 
ovoid,  sometimes  lobulated,  masses  in  the  subcutaneous  tissue.  They  are  always 
tumors  of  slow  growth.  They  are  sometimes  firm;  or  soft,  elastic,  almosl  semi- 
fluctuating  tumors.  They  are  movable  beneath  the  normal  skin;  as  they  are 
moved  the  skin  is  often  puckered  a  little  here  and  there  over  the  tumor.  A 
sense  of  crepitation  of  the  tat  lobules  can  sometimes  be  made  out  when  the 
tumor  is  grasped.  Lipomata  may  form  diffuse  tumors,  usually  in  the  neck; 
occasionally  they  be- 
come pedunculated. 
Congenital  lipoma 
occurs  as  a  tumor 
of  the  lumbar  re- 
gion and  hut  locks. 
If  pedunculated,  it 
may  form  a  so-called 
"  false  tail."  Lipo- 
ma occurs  in  cer- 
tain situations  more 
commonly  than  in 
others:  the  neck, 
the  hack,  shoulder, 
the  upper  and  low- 
er extremity.  They 
are  rare  on  the  face, 
rarer  still  on  the 
scalp.     In  addition 

to  subcutaneous  lipomata,  fatly  tumor  may  occur  in  a  variety  of  situa- 
tions. They  may  be  cutaneous,  subcutaneous,  submucous,  superitoneal, 
subfascial,  subsynovial  (lipoma  arborescens).  They  may  develop  within 
the  tendon  sheaths,  in  or  between  the  muscle-.  Fatty  tumor-  are  also 
found  in  connection  with  the  spinal  canal  as  the  remains  of  a  spina  bifida, 
and  also,  according  to  Sutton,  as  intradural  growths  of  fat.  Further  de- 
tails   in   regard    to    fatly    tumors    will    be    found    in    the   chapters    on    Regional 


FlQ.    62. —  FlBRO-LIPOMA    OF     1111.    BlJTTOC 

(Collection  of  Dr.  Charles  I..  Gibson.) 


228 


TUMOES 


Fig.  63. —  Lipoma  of  the  Shoulder. 
(Collection  of  Dr.  Charles  McBurney, 
Roosevelt  Hospital.) 


have  a  spiral  or  circular 
arrangement.  The  bun- 
dles may  be  closely  packed 
and  firm  and  the  consistence 
of  the  tumor  hard  (hard 
fibroma),  or  the  arrange- 
ment may  be  that  of  ordi- 
nary loosely  meshed  con- 
nective tissue  (soft  fibro- 
ma). The  ordinary  forms 
of  fibromata  are  character- 
ized by  slight  vascularity. 
Certain  combinations  of 
fibroma  with  lymphangio- 
ma and  angioma  occur  that 
contain  numerous  dilated 
blood-vessels  of  large  size, 
such  that  their  removal 
may  be  impossible.  The 
fibromata  occur  in  the  skin 
and  subcutaneous  tissue, 
in  the  sheaths  of  nerves,  in 
the  uterus  and  ovaries,  in 
the  bone  and  periosteum. 


Surgery.  The  lipomata  occur  most  com- 
monly during  middle  life — thirty  to  fifty 
years.  They  are  often  multiple.  They 
are  an  entirely  benign  tumor,  but  may 
grow  to  great  size  and  cause  serious 
symptoms  by  weight  and  pressure.  Li- 
poma is  sometimes  combined  with  fibroma 
as  fibro-lipoma ;  the  consistence  of  the 
tumor  is  then  more  firm.  Lipoma  may 
undergo  various  degenerative  changes,  or 
may  acquire  new  histological  characters 
and  be  converted  into  fibroma,  myxoma, 
and  sarcoma. 

Fibroma  —  Fibrous  Tumor.  —  Fibroma 
consists  histologically  of  bundles  of  white 
fibrous  connective  tissue,  arranged  some- 
times in  coarse,  waving  bands,  visible  to 
the    naked    eve.      Sometimes    the    bundles 


Fig.  64. — Multiple  Lipomata  of  the  Back  of  the  Neck. 
(New  York  Hospital,  author's  collection.) 


DIAGNOSIS    OF   THE    DIFFERENT    KINDS    oi     TUMORS 


229 


Fibroma  of  the  skin  occurs  in  I  wo  forms:  soft  fibroma  (fibroma  molluscum) 
and  ha rd  fibroma  (  keloid). 

Fibroma  molluscum. —  The  tumore  are  circumscribed  or  diffuse)  th< 
often  multiple  and  both  forms  frequently  occur  in  the  same  individual.     Tin: 
circumscribed  tumors  are  soft,  3essile,  or  pedunculated  tumors,  varying  in  size 
from  an  eighth  of  au  inch  to  an  inch  or  more  in  diameter.     They  are  co1  i 
with  normal  skin.     They  sometimes  occur  in  Large  numbers  in  the  same  indi- 
vidual, scattered  all  over  the  trunk  ami  extremities.     The  diffuse  form  causes 
;i  peculiar  thickening  of  the  skin 
and   subcutaneous   tissues   such 
that   the   skin    hangs   in   loose, 
soft    folds   from    the   face,    the 
scalp,   the  trunk,   or  elsewhere 
( cutis  pendula  ),  or  very   large 
tumors  may  be  formed,  weigh- 
ing many  pounds,  hanging  from 
the  genera]  integument.    The  tu- 
mors usually  grow  slowly,  and 
do  not  at  all  interfere  with  the 
health  of  the  individual.      The 
deformities  produced  are  some- 
times   extraordinary.       In    cer- 
tain   eases    combinations    occur 
with   angioma   and  lymphangi- 
oma;  pigmented   and  hairy   tu- 
mors are  thus  produced. 

Keloid. — A  hard  fibroma 
of  the  skin  and  suheutaueous 
tissues.  Keloid  usually  devel- 
ops in  scars  or  may  occur  spon- 
taneously. It  forms  a  pink  or 
red,  firm,  rather  flat  or  slightly 
elevated,  nonvascular  mass  of 
dense  fibrous  tissue.  Follow- 
ing burns  or  wounds,  it  takes 
the     form     of    the    seal',    grows 

-lowly,  ami  semis  out  prolonga- 
tions into  the  surrounding  skin. 
Owing  to  the  feeble  blood  sup- 
ply, it  is  prone  to  ulcerate  from 

slighl  traumatisms.  After  operative  removal,  keloid  recurs  almost  invariably  it 
undertaken  in  early  or  middle  life.  In  old  age  keloid  sometimes  undergoes  atro- 
phy, and  may  be  removed  with  a  fair  chance  of  cure.  Keloid,  as  well  as  other 
forms  of  fibrous  tumor,  is  more  frequent  in  the  negro  than  in  the  while  r. 


Fiq.  65. — Fibroma  molluscum.     (New  York    Hospital, 
service  of  1  >r.  Murray.  > 


230 


TUMORS 


Neurofibroma — False  Neuroma — Tubercula  dolorosum. — Fibroma 
of  the  hard  variety  often  develops  in  the  connective-tissue  sheath  or  framework 
of  a  nerve  trunk.  The  tumors  may  be  single  or  multiple  nodules,  rounded, 
ovoid,  or  spindle-shaped.  They  may  be  situated  in  or  beneath  the  skin.  The 
subcutaneous  variety  vary  in  size  from  that  of  a  small  bean  to  an  inch  or  more 


Fig.  66. — Soft  Fibroma  of  Buttock  and  Thigh.     (New  York  Hospital,  service  of  Dr.  Bolton.) 


in  length  and  thickness.  In  situation  they  correspond  to  a  nerve  trunk,  large 
or  small;  they  are  movable,  hard,  often  very  sensitive  and  painful.  (See  Neu- 
roma.) The  tender,  painful,  bulbous  tumors  growing  on  the  divided  ends  of 
nerve  trunks  in  the  stumps  of  amputated  limbs  are  fibromata,  though  they  some- 
times contain  nerve  fibers  of  new  formation.  In  the  internal  organs  the  com- 
monest example  of  fibroma  is  the  fibroma  of  the  uterus,  occurring  usually  in 


DIAGNOSIS    OF   THE    DIFFERENT    KINDS    OF   TUMORS  231 


combination  with  the  unstriped  musclfe  fibers  of  that  organ — fibro-myoma.  The 
tumors  are  single  or  multiple.  They  may  be  submucous,  subperitoneal,  «.r 
intramural;  they  occur  chiefly  in  the  body  and  near  the  fundus  of  the  organ, 
rarely  near  the  cervix,  and  of  any  size  from  thai  of  a  pea  to  thai  of  a  fetus 
ai  term  or  larger  l  Bee  Myoma  ). 

Periosteal  Fibkoma. —  Periosteal  fibroma  is  no1   uncommon  in  the  nasal 
fossse  and  antrum  of  Eighmore.     They  are  known  as  fibrous  polypi,  and  may 
reach  a  considerable  size,  obstruct- 
ing the  nasal  fossse  and  causing  de- 
formities of  the  bones  of  the  face 
( see  Face). 

Fibroma  occurs  in  combination 
with  other  tumors:  fibro-lipoma, 
fibro-myoma,  fibro-sarcoma,  fibro- 
neuroma,  fibro-angioma,  fibro- 
lymphangioma. 

Myxoma. — A  tumor  containing 
a  soft  tissue  composed  of  stellate 
nucleated  cells  with  delicate  inter- 
lacing processes  connecting  them 
with  other  similar  cells  embedded 
in  a  jelly  like  stroma  having  a  loose 
fibrous  reticulum.  This  tissue  is 
embryonal  in  type,  and  is  found  in 
the  umbilical  cord.  Myxoma  oc- 
curs as  a  distinct  tumor  rarely,  but 
is  a  common  form  of  degeneration 
in  the  connective-tissue  tumors,  both 
benign  and  malignant,  notably  in 
fibroma,  lipoma,  and  sarcoma  and 
enchondroma.  They  are  found  in 
the  same  situations  as  are  fibroma- 
ta, and  in  many  instances  are,  no 
doubt,  fibromata  which  have  under- 
gone   this    form    of    degeneration. 

They  may  be  met  with  in  the  brain  and  its  membranes.  Generally  myxomata 
are  benign  tumors,  but  they  not  rarely  become  converted  into  sarcomata,  and 
may  form  metastases  and  recur  after  removal. 

Enchondroma — -Chondroma. — Tumors  of  this  type  are  composed  of  cartilage, 
usually  hyaline  cartilage,  less  commonly  fibro-cartilage.  Cartilaginous  tumors 
arise  in  two  ways:  from  cartilage  or  bone  (exchondroma)  and  from  connect- 
ive tissue  (enchondroma).  The  first  class  may  crow  from  normal  cartilage 
anywhere  in  the  body.  The  scats  of  predilection  arc  the  epiphyseal  junctions 
of  the  long  bones,  the  costochondra]  junctions,  the  fingers,  the  periosteum  and 


Fig.  f>7. — Hard  Fibroma  of  the  Lobule  of  the 
Ear  (Keloid).  The  formation  of  keloid  tumors 
is  peculiarly  common  in  the  African  race.  In 
this  case  it  followed  perforation  of  the  lobule  of 
the  ear  made  fur  the  insertion  of  an  ear-ring.  A 
similar  tumor  formed  in  the  lobule  of  the  opposite 
ear. 


232 


TUMOES 


the  medulla  of  bones,  the  synchondroses.  As  mixed  tumors  containing  cartilage 
they  occur  in  the  mamma,  the  parotid  gland,  the  thyroid,  the  kidney,  and  the 
testis.  When  developed  from  connective  tissue,  or  from  displaced  cartilage  cells, 
they  occur  in  the  skin  and  internal  organs.  They  form  hard  nodular  tumors, 
usually  painless  and  of  slow  growth.  They  are  often  multiple,  and  may  exist  in 
large  numbers  in  the  same  individual.  They  usually  appear  in  young  persons. 
When  they  grow  at  the  junction  of  the  synovial  membrane  of  a  joint  with 
its  cartilage  (ecchondrosis)  they  may  become  detached  and  form  loose  bodies, 


Fig.  68. — Fibroma  Growing  in  the  Soft  Parts  over  the  Knee-joint.     This  tumor  had  undergone 
calcification.     It  was  a  very  hard  tumor.      (Collection  of  Dr.  Hitzrot.) 


or  "  floating  cartilages,"  so  called.  These  bodies  may  also  arise  by  the  forma- 
tion of  cartilage  in  the  synovial  tufts  of  the  joint,  becoming  detached  they  also 
form  floating  bodies.     Such  detached  chondromata  may  also  be  found  in  the 


DIAGNOSIS    OF   THE    DIFFERENT    KINDS    OF    TUMOE6 


antrum,  frontal  sinus,  and  ethmoidal  cells.     Chondromata  are  prone  to  mucous 
degeneration,  thus  cavities  and  cysts  are   formed   in  the  tumor.     They  may 
undergo  ossification,  complete  or  partial.     They  are  usually  benign  tin 
but  may   rarely   form   me- 
tastases.     The    mosl     fre- 
quent   combinations     with 
oilier  tumors  are  osteochon- 
dromata    and    chondrosar- 
COmata.       The   parotid   and 
testicular   tumors   contain- 
ing cartilage  are  often  sar- 

< lata    or    mixed    tumors 

containing  a  rariety  of  tis- 
sue elements. 

Osteoma — Bony  Tumors. 
— Osteomata  usually  de- 
velop from  bone  or  carti- 
lage, bul  may  arise  from 
other  tissues  by  displace- 
ment of  fetal  bony  ele- 
ments or  from  injury. 
Thus,  bony  tumors  may  be 
formed  in  the  skin,  mus- 
cles, tendons  and  their  sheaths,  the  parotid  gland  and  testis,  and  even  in  the 
brain.  They  consist  of  dense  bony  tissue  or  of  cancellous  tissue.  ( Jertain  bony 
tumors  develop  from  the  periosteum  of  the  skull,  which  are  as  hard  and  dense  as 
ivory;  these  sometimes  grow  in  the  frontal  sinus,  from  the  mastoid  process  and 
the  angle  of  the  jaw.  The  bony  tumors  composed  of  cancellous  tissue  occur  most 
commonly  at  the  epiphyseal  junctions  of  the  long  bones;  they  are  covered, 
while  growing,  with  a  layer  of  cartilage.  They  may  he  pedunculated  tumors, 
and  may  become  detached  by  traumatism.  Bony  outgrowths  of  considerable 
size  may  occur  at  the  site  of  fractures.  Cavalrymen  sometimes  develop  a  bony 
tumor  in  the  adductor  longus  muscle.  A  small  bony  tumor  of  cancellous 
tissue  covered  by  cartilage  sometimes  develops  from  the  dorsal  surface  of  the 
terminal  phalanx  of  the  great  toe  in  young  persons  and  children;  the  nail  is 
pushed  up  in  front  of  the  tumor.  Some  bony  tumor-  growing  from  the  perios- 
teum are  movable  upon  the  hone  beneath. 

A  bony  outgrowth  is  usually  called  an  exostosis.  When  developed  in  the 
interior  of  a  bone,  it  is  spoken  of  as  an  enostosis.  A  bony  tumor  as  it  ap- 
proaches the  -kin  may  develop  a  bursa  upon  it-  surface.  Sometimes  such  a 
bony  outgrowth  arises  from  the  interior  of  a  joint,  ami  may  push  the  synovial 
membrane  in  a  pouch  before  it.  This  pouch  may  or  may  not  remain  in  com- 
munication with  the  joint.  Such  bursas  contain  clear,  viscid  fluid,  and  some- 
times  small   loose   pieces   of  hyaline   cartilage.      A    favorite   Site    13   beneath   the 


Fig.  69. — A  Lipoma  in  mi:  Popliteal  Spa<  e.     A  rare  situation. 
The  patient  was  a  bov  aged  thirteen  years.     The  tumor  was 
firsl  observed  when  be  was  four  years  old;  ami  during  the 
year  preceding  its  removal  it  had  doubled  in  size.     (( 
Dr.  Ellsworth  Eliot.) 


234  TT7M0ES 

ligamentum  patella?.  This  combination  of  a  bony  tumor,  surmounted  by  a 
bursa,  has  received  the  name  exostosis  bursata.  The  diagnosis  of  bony  tumors 
is  made  from  their  hard  consistence,  their  situation,  their  frequent  attach- 
ment to  and  origin  from  bone,  and  their  slow  growth.  As  already  indicated, 
they  may  be  sessile  or  pedunculated,  of  rounded  or  irregular  contour,  even 
spiny.  Under  the  microscope  they  exhibit  the  histological  characters  of  true 
bone.  The  X-rays  furnish  valuable  aid  in  determining  the  shape,  size,  and 
attachments  of  bony  tumors,  when  not  superficial. 

Odontoma — Tooth  Tumors. — The  following  description  of  odontomata  is 
taken  from  an  article  on  tumors  by  Dennis,  "  Dennis's  System  of  Surgery,"' 
vol.  iv,  p.  59 : 

The  tumor  takes  its  origin  from  a  tooth  germ;  if  the  tumor  arises  from  the 
enamel  it  is  termed  an  epithelial  odontoma;  if  from  the  fibrous  tissue,  a  fibrous 
odontoma ;  if  from  the  tooth  follicle,  a  follicular  odontoma ;  if  from  the  tooth 
cement,  a  cementoma;  if  from  the  crown  of  the  toothy  a  radicular  odontoma;  if 
from  all  the  tooth  structure,  it  is  termed  composite  odontoma.  The  epithelial  odon- 
toma usually  occurs  about  the  twentieth  year,  and  is  generally  found  in  connection 
with  the  horizontal  portion  of  the  inferior  maxilla.  The  tumor  is  inclosed  in  a 
capsule,  within  which  are  the  multiple  and  diminutive  cysts  varying  in  size  and 
shape  and  containing  a  coffee-colored  mucoid  fluid.  The  histological  structure  con- 
sists of  columns  of  epithelium  which  divide  and  subdivide,  and  in  some  cases 
branches  of  one  column  are  ingrafted  upon  that  of  another.  If  ulceration  occurs 
in  the  mucous  membrane,  the  ajmearanee  is  very  similar  to- epithelioma,  for  which 
it  must  not  be  mistaken. 

The  fibrous  odontoma  consists  of  a  tooth  contained  in  its  sac,  which  has  become 
so  thickened  by  the  deposit  of  fibrous  tissue  that  it  will  not  permit  the  escape  of 
the  tooth.  In  consequence  of  this  environment  the  development  of  the  tooth  is 
arrested.  In  the  meshes  of  the  fibrous  sac  chalky  concretions  are  often  deposited. 
This  variety  of  odontoma  may  be  situated  in  the  ramus  of  the  jaw,  or  in  the 
maxillary  portion  and  project  into  the  antrum,  especially  in  children  at  the  time 
of  the  eruption  of  the  second  teeth. 

The  follicular  odontoma  is  a  tumor  occurring  between  the  tenth  and  twentieth 
years,  and  is  formed  by  the  union  of  several  denticles.  The  capsules  connect  with 
each  other  and  ossification  occurs  in  the  membrane.  Thus  the  union  of  several 
denticles  forms  a  confound  follicular  odontoma,  and  when  one  tooth  alone  is 
involved  a  simple  follicular  odontoma  is  developed.  The  latter  may  involve  the 
permanent  teeth,  notably  the  molars.  If  the  wall  of  the  cyst  is  very  attenuated, 
eggshell  crepitation  may  be  present.  The  cyst  contains  the  tooth  surrounded  by 
a  viscid  fluid.  The  tooth  may  be  found  in  its  proper  position,  or  may  be  turned 
upon  its  side  or  inverted.  The  cysts  may  be  bilateral  or  they  may  be  multiple. 
The  surgeon  should  examine  to  see  if  the  tooth  has  appeared,  as  its  absence  points 
to  the  diagnosis  of  a  follicular  odontoma,  since  this  variety  can  only  exist  in  con- 
nection with  the  nonappearance  of  a  tooth  or  teeth. 

Cementoma  is  a  tumor  composed  of  a  tooth  which  is  lodged  in  a  hard  substance 
like  cementum  and  surrounded  by  a  capsule,  which  is  not  only  enlarged  but  very 
much  thickened  by  the  increase  of  fibrous  tissue.    A  radicular  odontoma  is  a  tumor 


DIAGNOSIS   OF   THE    DIFFERENT    KINDS    OF   TUMORS         235 

composed  of  dentine  and  cementum,  and  grows  from  the  roote  of  the  tooth,  3ince 
in  the  process  of  evolution  the  crown  of  the  tooth  is  already  Formed.     The  com- 

■pusilr  odontoma  is  composed  of  the  d i fferenl  structures  which  enter  into  the  forma- 
tion of  a  tooth.  Usually  several  tooth  germs  are  united  -<>  ae  to  form  an  irregular 
mass  which  bears  but  little  resemblance  to  a  human  tooth.  The  tumor  is  situated, 
in  about  two  thirds  of  the  cases,  in  the  ramus  of  the  jaw,  and  in  the  other  third 
in  the  maxilla.  II'  it  Bprings  from  the  upper  jaw  it  may  invade  the  antrum  and 
produce  deformity  of  I  he  lace. 

The  diagnosis  of  these  tumors  connected  with  the  teeth  is  to  be  made  from 
the  youth  of  the  patient;  the  situation  of  the  tumor;  the  absence  of  the  ordinary 
Bigns  of  malignancy.  A  central  sarcoma  of  the  giant-celled  variety  in  the  lower 
jaw,  where  the  cortical  layer  of  bone  is  preserved,  although  dilated,  may  lend 
to  confusion  even  after  the  tumor  is  removed;  since  tissues  resembling  sar- 
coma, including  giant  cells,  are  often  found  in  growing  bone.  (For  Osteo- 
sarcoma, see  Sarcoma.) 

Angioma. — Tumors  containing,  or  consisting  of,  abnormally  developed  blood- 
vessels. Three  forms  exist:  (1)  Angioma  simplex;  (2)  Cavernous  angioma; 
(3)  Cirsoid  aneurism. 

1.  Angioma  Simplex  (Nevus  vasculosus) — Plexifobm  Angioma — 
Telangiectasis  (Birth-mark). — A  flat  or  slightly  elevated  tumor,  usually  «»f 
the  skin,  congenital,  or  developed  during  infancy.  The  tumor  is  pink,  rod.  or 
blue  in  color,  according  to  the  preponderance  of  arteries  or  veins  in  its  struc- 
ture, and  is  sharply  circumscribed.  It  contains  numerous  capillaries  and  small 
vessels  arranged  in  a  tortuous  manner  in  the  skin.  These  growths  occur  with 
especial  frequency  upon  the  face  and  scalp.  The  area  covered  varies  in  size 
from  a  fraction  of  an  inch  in  diameter  to  a  large  portion  of  the  trunk  or  an 
extremity.  The  tumor  may  remain  of  the  same  size  or  grow  in  extent  slowly 
or  rapidly.  Sometimes  nevi  are  covered  by  a  thick  growth  of  hair,  resembling 
the  fur  of  a  cat  or  monkey.  Their  occurrence  is  sometimes  attributed  by  mothers 
to  mental  impressions  during  pregnancy.  The  diagnosis  is  simple  from  the 
foregoing  description. 

2.  Cavernous  Angioma. — This  tumor  occurs  in  the  subcutaneous  tissues 
and  in  tlie  internal  organs,  the  liver,  spleen,  and  kidney,  as  well  as  in  the 
brain  and  in  the  bones.  The  tissue  of  which  these  tumors  are  composed  re- 
sembles that  of  the  corpus  cavernosum  penis — that  is  to  say,  the  blood  flows 
through  intercommunicating  vascular  spaces  rather  than  narrow  channels. 
The  vessels  and  spaces  are  very  much  larger  than  is  the  case  with  nevus. 
The  disease,  is  congenital  or  developed  in  infancy  (except  that  it  may  develop 
in  the  interna]  organs  of  old  persons),  and  tends  to  increase  in  size.  The  skin 
is  normal  or  blue  in  color  over  the  tumor;  the  tumor  may  pulsate.  When 
compressed  with  the  fingers  the  blood  is  readily  squeezed  oul  of  the  vessels, 
but  when  the  pressure  ceases,  immediately  returns  and  the  tumor  resumes 
its  former  size.  Sometimes  these  tumors  are  very  large,  and.  if  wounded. 
Berious  or  fata]  bleeding  may  occur. 


236 


TUMOKS 


3.  Cirsoid  Aneurism — Aneurysma  Racemosum — Angioma  Arteriole 
Racemosum — Aneurism  by  Anastomosis. — A  tumor  composed  of  a  con- 
geries of  dilated  tortuous  arteries.  The  most  frequent  site  is  the  scalp  and 
face.  The  branches- — namely,  of  the  external  carotid  artery — and  of  these, 
the  temporal  is  most  often  affected.  It  occasionally  appears  upon  the  hand 
and  fingers.     It  is  more  frequent  in  women  than  in  men,  and  is  a  disease 


Fig.  70. — Cavernous  Angioma,  Congenital.     The  child  had  an  extensive  area  involving  the  scalp, 

the  forehead,   and  the  eyelids. 

Note.— -She  was  sent  to  me  by  Dr.  John  E.  Weeks.  The  tumor  was  cauterized  by  Dr.  Charles 
McBurney  in  the  Roosevelt  Hospital.  The  black  area  shown  in  the  picture  had  been  cauterized  with 
the  actual  cautery  one  week  before  the  picture  was  taken.  No  marked  improvement  could  be  obtained 
by  this  means  and  I  believe  the  child  subsequently  died  from  hemorrhage.  (Collection  of  Dr.  Charles 
McBurney.) 

of  early  life — ten  to  thirty-five  years.  The  dilated,  tortuous,  and  thickened 
arteries  form  a  not  very  prominent  tumor;  the  surface  is  uneven  or  wavy, 
and  the  boundaries  are  somewhat  irregular  in  outline.  Often  large  tortuous  ves- 
sels can  be  seen  or  felt  running  from  the  periphery  toward  the  central  mass. 
The  skin  is  usually  somewhat  movable  over  the  vessels  beneath,  but  at  points 
it  may  be  adherent.  The  tumor  is  soft  and  compressible,  pulsates  distinctly, 
and  a  soft  murmur  may  be  heard  over  it  upon  auscultation.  The  disease  is 
to  be  distinguished  from  an  arterio-venous  aneurism  by  the  absence  of  a  his- 
tory of  injury,  by  the  fact  that  the  latter  disease  is  of  more  rapid  development 
and  shows  a  more  marked  murmur  on  auscultation  and  often  a  thrill.     In 


DIAGNOSIS    OF   THE    DIFFERENT    KINDS    OF    TUMORS 


237 


arterio-venous   aneurism    the   arteries    leading   to    the   central    tumor   are    not 

dilated,  and  in  this   latter  affection,  if  the   point   <•!"  < munication   between 

the  artery  and  the  vein  can  l>e  found,  pressure  upon  it  will  Btop  the  pulsa- 
tion and  the  murmur.  Angioma  sometimes  occurs  in  combination  with 
other  forms  of  tumor,  notably  with  fibroma,  lipoma,  lymphangioma,  and 
sarcoma. 

Lymphangioma. —  In  these  tumors  dilated  lymph  vessels  exist  as  dilated 
blood-vesels  d<>  in  the  angiomata.     They  may  !«■  divided    into  three  classes: 

1.  Lymphangioma  Simplex  <>k  Lymphatic  Nevus. — Tin •  tumors  may 
occur  in  various  part-  of  the  body.  Their  mosl  common  sites  are  the  -kin,  the 
mucous  membrane,  and  the 
Buhcutaneous  tissues.  They  are 
found  in  the  tongue,  producing 
the  condition  known  as  macro- 
glossia,  in  which  the  tongue 
becomes  so  much  enlarged  that 
it  cannot  be  retained  in  the 
mouth.  A  similar  condition 
occurs  in  the  lips,  and  produces 
thickening  and  deformity — 
macrocheilia.  A  dilatation  and 
increase  in  numher  of  lymph 
vessels,  with  thickening  of  their 
walls,  i-  a  part  of  elephantia- 
sis. The  neck,  the  groin,  and 
the  axilla  are  occasional  sites. 
The  tumor  may  be  large  or 
small.  It  is  soft  and  com- 
pressible.  The  dilated  lymph 
vessels  may  sometimes  be  felt 
like  a  bundle  of  soft  worms 
beneath  the  skin.  The  skin 
may  be  normal  or  pink  in 
color  over  the  tumor.  The  dis- 
ease is  not  attended  by  pain. 
If  wounded,  a  lymph  fistula 
may  result,  with  a  continuous 
draining  away  of  a  watery 
fluid,  usually  clear,  sometimes 
milky. 

-.  Cavernous  Lymphangioma  (Congenital  Lymphangiectasis). — In  cav- 
ernous Lymphangioma  the  lymph  channels  are  dilated  into  large  spaces  by 
thinning  and  final  disappearance  of  their  walls.  The  walls  of  neighboring 
veins  may  also  give  way;  the  cavities  then  become  filled  with  blood. 


Fig.  71.-  Mixed  Venous  and  Lymphangioma  of  the 
I  \i  i  .  A  congenital  tumor  which  had  very  slowly  in- 
creased in  size.  Large  dilated  venous  spaces  showed 
blue  through  the  skin  of  the  face.  Tumor  inoperable. 
(Collection  of  Dr.  Charles  McBurney.) 


238  TUMORS 

3.  Cystic  Lymphangioma. — Cystic  lymphangioma  occurs  most  often  as 
a  congenital  tumor  of  the  neck  in  the  submaxillary  region.  The  cyst  is  some- 
times multilocUlar  and  of  uneven  surface,  the  wall  may  be  thin  and  the  tumor 
translucent,  or  thick  and  dense,  resembling  the  condition  of  elephantiasis. 
The  cyst  may  grow  slowly  or  rapidly ;  in  the  latter  case  the  tumor  may  hang 
down  as  far  as  the  clavicle,  or  on  the  shoulder  and  extend  upward  to  the 
zygoma.  Severe  or  even  fatal  pressure  symptoms  may  be  produced  in  the 
larynx,  trachea,  esophagus.  Fluctuation  is  usually  appreciable,  but  may  be 
obscured  on  account  of  the  extreme  tension  of  the  fluid.  Pulsation  may  be 
felt  where  the  cyst  overlies  the  vessels.  Similar  tumors  may  occur  at  the 
back  of  the  neck,  beneath  the  occiput,  and  in  the  axilla.  These  cystic  lym- 
phangiomata  often  become  inflamed;  after  the  subsidence  of  the  inflamma- 
tion cure  may  follow  by  atrophic  changes  in  the  cyst  wall. 

Glioma. — These  tumors  occur  in  the  central  nervous  system,  in  the  brain, 
much  less  often  in  the  spinal  cord.  They  consist  of  that  form  of  connective 
tissue  which  forms  the  framework  of  the  central  nervous  system  (neuroglia). 
They  are  soft  or  semifluid  tumors,  usually  with  imperfectly  marked  boundaries. 
According  as  they  are  more  or  less  vascular,  they  are  red,  grayish-white,  or  gray 
in  color.  They  may  be  so  vascular  as  to  resemble  angiomata.  They  do  not 
form  metastases.  Certain  forms  of  glioma  are  found  to  consist  of  ganglionic 
nerve  cells  and  newly  formed  nerve  fibers  (Ziegler,  Klebs,  Heller). 

Neuroma  (see  Neuro-fibroma). 

Plexiform  Neuroma. — A  peculiar  degenerative  change  in  the  sheaths  of 
peripheral  nerves  such  that  they  become  enlarged,  thickened,  tortuous,  and 
may  form  a  considerable  tumor  beneath  the  skin.  They  commonly  occur  in 
conjunction  with  pigmentation  of  the  skin  and  the  development  of  hair — in 
fact,  beneath  a  hairy  mole — in  some  cases  without  these  accompaniments.  The 
tumor  may  involve  the  trunk  of  one  or  several  nerves.  The  mass  of  convo- 
luted nerves  resembles  in  appearance  a  bunch  of  white  worms  with  bulbous 
enlargements  here  and  there  on  individual  trunks.  In  many  cases  the  sheaths 
of  the  nerves  have  undergone  mucous  degeneration,  and  may  be  almost  trans- 
lucent. They  are  almost  confined  to  the  subcutaneous  tissues,  and  occur  in 
various  situations.  According  to  Bruns,  in  forty  cases  the  tumor  occurred 
fifteen  times  on  the  temples  and  upper  eyelid;  eight  times  in  the  back  part 
of  the  neck;  three  times  on  the  nose  and  cheek;  four  times  beneath  the  jaw 
and  front  part  of  the  neck;  seven  times  on  the  breast  and  back,  and  three 
times  on  the  extremities  (Tillmanns).  In  two  cases  which  I  have  seen  one 
formed  a  slightly  rounded  bulging  tumor  four  inches  in  diameter  in  the  dorsal 
region  of  the  back  to  one  side  of  the  middle  line.  The  tumor  was  soft,  almost 
fluctuating,  and  thought  before  operation  a  lipoma.  In  the  second  case  a  soft, 
bulging  mass  could  be  seen  and  felt  in  the  submaxillary  region  extending  well 
down  to  the  clavicle.  (Case  of  Dr.  Kobert  Abbe.  See  Tumors  of  the  Neck.) 
Both  cases  were  in  children.     In  neither  was  pigmentation  or  hairiness  present. 

Plexiform  neuromata  may  form  tumors  of  considerable  size;  they  are  not 


DIAGNOSIS    OF   THE    DIFFERENT    KINDS    OF    TI'MOKH 


239 


malignant,  and  ;ir<'  nol  usually  painful.  True  neuromata  thai  is,  tumors 
made  up  in  part  of  newly  formed  nerve  elements  are  rare.  They  may,  bow- 
ever,  occur  in  the  trunks  of  the  peripheral  nerves  as  tumore  formed  of  medul- 
[ated  or  nonmedullated  nerve  fibers,  and  may  form  tumors  of  considerable 
size.  They  may  be  painful.  Another  form  of  neuroma  containing  ganglionic 
nerve  cells,  known  as  ganglionic  neuroma,  is  rarely  observed  in  the  brain  and 
spinal  cord,  in  the  testis  and  ovary,  and  in  the  sympathetic  nervous  system. 
These  tumors  are  usually  of  slow  growth  and  benign,  rarely  malignant.  Fibro- 
neuromata  may  undergo  sarcomatous  degeneration,  and  primary  Barcoma  of 

the  nerve  t  ninks  also  occurs. 

Myoma — Muscle  Tumor. — Muscle  tumor  occurs  in  two  forms:  The  one  con- 
sists of  unstriped  muscle  fiber,  myoraa-kevicellulare  (leiomyoma),  and  rhabdo- 


FlQ.  72. — Submucous  I'i  mho-myoma  of  the  Uterus.     (New  York  Hospital  collection.) 


myoma,  myoma-strio-cellulare,  which  consists  of  muscle  of  the  striped  variety. 
The  former  is  very  common,  the  latter  very  rare.  Myoma  of  the  unstriped 
variety  consists  of  bundles  of  unstriped  muscular  fibers  variously  arranged  ami 
usually  combined  with  a  greater  or  less  amount  of  ordinary  fibrous  tissua 
The  muscle  cells  can  he  distinguished  from  the  fibrous  tissue  by  their  nuclei, 
their  long,  spindle  shape,  and  their  arrangement  in  bundles  or  whorls.  They 
occur  most  often  in  the  uterus  (see  Fihro-niyoma )  ami  in  the  muscular  coats 
of    the    intestinal    tract,    occasionally    from    the    muscular    coal    of    the    blood- 

vessels.  The  tumors  are  nodular  and  of  firm  consistence.  They  are  usually 
of  slow  growth,  Imt  may  in  time  attain  an  enormous  size.  Occasionally  they 
grow  (piite  rapidly.  Uterine  myomata  cause  various  symptoms  -bleeding, 
pressure  symptoms  upon  the  bladder,  rectum,  and  uterus,  and  interference 
with  pregnancy.     These  tumors  are  prone  to  various  forms  of  degeneration — 


240 


TTTUORS 


myxomatous  and  fatty  degeneration,  calcification.      Cystic  cavities  may  form 
in  their  interior.     They  may  slough  and  die  en  masse,  or  the  necrosis  may  he 

localized.  Occasionally  ma- 
lignant degeneration  may 
occur. 

Rhabdomyoma.  —  Tu- 
mors consisting  merely  of 
striped  muscular  fiber  are 
rare.  Rhabdomyosarcomata 
are  less  so.  They  occur  as 
congenital  tumors  in  the 
testis,  kidney,  and  ovary. 
The  muscle  fibers  exist 
in  combination  with  other 
types  of  tissue.  They  are 
often  called  mixed  tumors. 
Pseudoleukemia — Hodg- 
kin's  Disease  —  Malignant 
Lymphoma. — While  pseu- 
doleukemia cannot  be 
classed  with  the  true  tu- 
mor formations,  yet,  from 
the  clinical  diagnostic  point 
of  view,  it  has  been  thought 

Fig.  73. — Mtttiple  Fibro-mtomata  of  the  Ltertts.  .  ... 

(New  York  Hospital,  service  of  Dr.  Stimson.)  best    to    Consider    it    in    this 


Fig.   74.- 


-FlBRO-MYOMA     OF    THE     FtERUS    WITH     DOUBLE     HeMATO-SaLPIXX. 

(New  York  Hospital,  service  of  Dr.  F.  H.  Markoe.) 


DIAGNOSIS   OF   THE    DIFFERENT   KINDS   OF   TUMORS 


241 


place.  Tin1  disease  is  characterized  by  progressive  enlargement  of  the  lymph 
nodes  throughoul  the  body.  By  the  formation  of  nodular  masses  of  hyper- 
plastic lymphoid  tissue  in  the  lymphatic  vessels  of  various  tissues  and  organs. 
By  enlargement  of  the  spleen,  of  a  variable  degree,  due  to  the  formation  of 
lymphoid  tissue  in  its  substance;  usually  the  spleen  is  considerably  increased 
in  size.  By  a  slowly  or  rapidly  progressive  anemia  (loss  of  red  cells  ;m<l  of 
hemoglobin  ).  I  ly  a  normal  or 
diminished  number  of  leuco- 
cytes. ( In  certain  eases  and 
limes  the  white  cells  may  lie 
moderately  increased,  but  the 
increase  does  not  exceed  that 
found  in  inflammatory  condi- 
tions, and  never  approaches 
that  found  in  leukemia).  In 
some  cases  by  acute  febrile  at- 
tacks of  variable  duration.  By 
slow  or  rapid  loss  of  flesh  and 
strength,  and  finally  by  death 
from  tuberculosis  or  from  the 
local  mechanical  effects  of  the 
masses  of  lymphoid  tissue  press- 
ing upon  the  air  passages,  etc.; 
from  some  intercurrent  disease 
other  than  tuberculosis;  from 
exhaustion. 

The  disease  begins  by  the 
simultaneous  or  successive  en- 
largement of  lymph  glands,  usu- 
ally  on   one   side   of  the   neck  ; 

the     glands    upon,    the    opposite        FlG-   75— Recurrent   Lympho-sarcoma    with   Mtcji*. 
•  l  li  ple    Localizations  (Hodqkjn  s    Disease).     (Colieo- 

Side  then  enlarge,  and   the  whole  tion  of  Dr.   L.   W.   Hotchki.ss,    Bi'llovue  Hospital.) 

chain   is   affected    at  once,    and 

often  quite  suddenly.  The  axillary,  mediastinal,  mesenteric,  and  inguinal 
glands  are  successively  involved,  and  masses  of  new  lymphoid  tissues  later 
appear  in  various  tissues  and  organs.  Retroperitoneal  and  mesenteric  tu- 
mors of  this  kind  may  reach  a  considerable  size,  and  be  easily  palpable 
through  the  abdominal  wall.  The  glands  are  round,  soft,  or  firm,  and 
movable  upon  one  another  and  upon  the  surrounding  parts  until  a  late  stage 
in  the  disease,  when  they  may  become  fused  by  periadenitis,  rarely  by  dis- 
appearance of  their  capsules.  They  are  painless  and  insensitive,  and  cause 
inconvenience  from  deformity  and  pressure.  The  individual  glands  vary  in 
size   from  that  of  a  pea  to  that  of  an  apple.      The  skin   remains  normal  over 

the  tumors. 
17 


242 


TUMORS 


The  growth  of  the  glands  and  the  infection  of  new  sets  of  glands  is  not  a 
steady,  slowly  progressive  process.  The  glands  of  a  region  become  enlarged 
to  a  certain  size,  and  may  change  but  little  for  weeks  or  months.  Suddenly 
they  begin  to  grow  quite  rapidly,  new  tumors  appear  in  the  region  already 
involved,  and  new  sets  of  glands  enlarge  in  other  regions.  The  glands  do  not 
suppurate  or  break  down  or  become  cheesy.  There  is  no  tendency  to  infil- 
tration of  the  surrounding  structures,  nor  can  a  continuity  of  new  lymphoid- 
tissue  formation  be  traced  from  one  set  of  glands  to  a  neighboring  chain;  in 
these  two  latter  traits  the  disease  differs  from  true  lymphosarcoma. 

The  histological  structure  of  the  glands  cannot  be  differentiated  from 
an  ordinary  lymphatic  hyperplasia.  In  the  soft  form  the  glands  are 
pink    or    reddish    gray    on    section,     and    very    soft.       Microscopically    an 

enormous  increase  in 
lymph  corpuscles  is  ob- 
served (small  and  me- 
dium-sized lymphocytes, 
a  few  polynuclear  leu- 
cocytes), small  giant 
cells,  epithelioid  cells, 
and  eosinophile  cells. 
The  lymph  paths  are 
obliterated  in  the  later 
stages  and  in  rapidly 
progressive  forms  of  the 
disease.  The  presence 
of  eosinophile  cells  is  re- 
garded by  Dietrich  and 
Fischer  as  of  diagnos- 
tic importance  (Ewing). 
In  the  hard  form  the 
lymphoid  cells  are  large- 
ly replaced  by  a  dense 
fibrous  reticulum.  The 
glands  are  nearly  white 
on  section,  smaller,  and 
of  firm  consistence. 
Both  forms  may  occur 
side  by  side.  The  hard 
form  is  probably  an 
older  phase  °f  the 
process. 
The  patients  are  usually  young — ten  to  forty  years  of  age.  In  advanced 
life  the  disease  occurs,  but  is  uncommon.  In  the  more  rapid  cases  there  occur 
from  time  to  time  sharp  attacks  of  fever,  lasting  a  few  days  or  a  fortnight,  or 


Fig.  76. — Diffuse  Fibro-i.ymphangioma  of  Lower  Extremity 
(Nonparasitic,  Elephantiasis).  (Medical  service,  New  York 
Hospital,  Dr.  Peabody.) 


DIAGNOSIS    OF    THE    DIFFERENT    KINDS    OF    TUMORS 


243 


even  longer.     The  temperature  rises  gradually,  and  may  reach  104°— 105°  F. 
The    local   conditions    remain    unchanged.      The    fever   usually    subsides   sud- 
denly, and  the  patient  may  almost  resume  his  ordinary  health.     During  these 
febrile  attacks  pure  cultures  of 
Staphylococcus  pyogenes  aureus 
have   been  cultivated  from   the 
blood    and    from    the    substance 
of   the   enlarged    glands.      The 
condition  was  not  attended  by 
suppuration.     Different  observ- 
ers regard  the  presence  of  pyo- 
genic germs  variously.     Ebstein, 
Pel,  and  others  consider  this  an 
essential  factor  in  the  disease ; 
Fischer  as  a  mixed  infection. 

As  the  disease  progresses, 
emaciation,  anemia,  anorexia, 
diarrhea,  edema  of  the  extrem- 
ities, and  ascites,  cough  and 
dyspnea  from  pressure  upon  the 
trachea  or  upon  the  recurrent 
laryngeal  nerves,  are  added. 
Fatal  dyspnea  from,  pressure 
by  enlarged  mediastinal  glands 
may  occur  before  the  general 
condition  is  seriously  impaired. 
I  saw  such  a  case  end  fatally, 
while  the  glands  in  the  neck 
were  only  moderately  enlarged, 
and  the  patient,  a  youth  of 
eighteen,  was  still  well  nour- 
ished and  in  fair  general  health. 

Combinations  with  tuberculosis  occur  not  infrequently  in  pseudoleukemia.  The 
tuberculosis  may  be  generalized  or  may  affect  the  enlarged  glands.  In  certain 
cases,  also,  transition  forms  appear  to  exist  between  pseudoleukemia  and  true 
lymphosarcoma. 

Differential  Diagnosis. — If  tuberculosis  is  suspected,  a  gland  may  be 
removed,  and  examined  on  section  with  the  naked  eye  and  by  the  microscope 
for  caseous  areas,  miliary  tubercles,  hyaline  degeneration,  and  the  presence  of 
tubercle  bacilli.  Guinea  pigs  may  also  be  inoculated  with  the  suspected  tissue. 
From  true  leukemia  the  disease  must  be  differentiated  by  the  marked  leuco- 
cytosis  in  the  former.  From  lymphosarcoma  by  the  mode  of  growth  and  dis- 
semination characteristic  of  the  sarcomata,  and  the  infiltration  of  surrounding 
tissues.     Syphilitic  infection  on  the  lips  or  interior  of  the  mouth  and  throat 


Fig.  77. — Ulcerated  and  Inoperable  Sarcoma  of 
Ribs,  Pleura,  and  Pericardium.  Duration  of  growth 
nine  months  only.  Female  aged  twenty-eight.  Death 
from  hemorrhage  and  acute  septicemia.  (Collection 
of  Dr.  F.  W.  Murray.) 


244 


TTTMOKS 


is  attended  by  sudden,  painless  enlargements  of  the  lymph  nodes.  The  primary 
lesion  is  usually  evident.  In  inflammatory  hyperplasia  of  lymph  nodes  some 
source  of  external  irritation  or  infection — a  carious  tooth,  a  pediculosis  capitis, 
an  eczema,  a  discharge  from  the  ear,  etc. — will  be  noted.  Acute  inflammatory 
conditions  of  the  cervical  lymphatics  follow  a  focus  of  infection  upon  the  skin 
or  mucous  membrane,  or  occur  in  the  course  of  an  acute  infectious  disease. 

The  pain  and  other  signs  of 
pyogenic  infection,  together 
with  leucocytosis,  establish  the 
diagnosis.  Secondary  carci- 
nomatous and  sarcomatous  dis- 
ease of  the  cervical  lymph 
nodes  follow  a  primary  growth 
usually  of  a  quite  evident  char- 
acter. I  have  seen  but  two 
cases  of  carcinoma  of  the 
lymph  nodes  of  the  neck  in 
which  no  primary  focus  could 
be  found. 

Sarcoma.  —  Sarcomata  are 
developed  from  connective  tis- 
sue. Histologically  they  re- 
semble the  partly  differenti- 
ated connective  tissues  of  the 
embryo.  The  cellular  elements 
are  in  excess  of  the  intercellu- 
lar substance,  and  the  charac- 
ter of  the  cells  is  often  of  an 
abnormal  and  aberrant  type. 
Certain  types  of  sarcoma  are 
unquestionably  the  most  dead- 
ly forms  of  malignant  disease. 
In  rapidity  of  growth,  in  in- 
sidious infiltration  of  surround- 
ing tissues;  in  precocious  dis- 
semination they  are  unequaled 
by  any  form  of  carcinoma. 
Their  early  diagnosis  is  corre- 
spondingly important ;  unfor- 
tunately, it  is  in  many  instances 
correspondingly  difficult. 
Sarcomata  consist  of  cells  of  various  shapes  and  sizes  embedded  in  a  fibril- 
lary, homogeneous,  myxomatous,  or  reticulated  intercellular  substance.  The 
cells  may  be  small  and  round,  with  a  large  nucleus  and  a  small  amount  of  cell 


Fig.  78. — Sarcoma  of  the  Shotjlder-beade.     (Collection 
of  Dr.  Charles  McBurney,  Roosevelt  Hospital. ) 


DIAGNOSIS    OF    THE    DIFFERENT    KINDS    OF    TUMORS 


245 


protoplasm,  or  round  and   large,  spindle-shaped,  stellate,  or  the  cells   ma^    be 

larger  and  Itinuelear  gianl  eel!-'.     In  -dine  cases  cells  of  various  shapes  are 

found   together  :m<l   in  apposition   in  the  Bame  tumor.     The  blood   supply  of 
sarcomata    is    variable    but 
generally  abundant,  i  be  ves- 
sels are  largely  capillaries; 

they   may   be   so   ai irous 

that  the  I umor  pulsates,  and 
ihns  resembles  an  aneurism  ; 
there  may  even  be  an  audi- 
ble murmur.  The  cells  of 
these  tumors  are  in  close 
eoiitact  with  the  caliber  of 
the  blood-vessels.  Sarcom- 
ata possess  no  lymphatics. 
These  tacts  serve  to  explain 
their  dissemination  by  the 
veins  rather  than  by  the 
lymph  channels.  Seme 
forms  of  sarcoma  possess  a 
capsule,  and  may  remain 
long  within  it — coil  nil  os- 
teosarcoma ;  others  are  in- 
filtrating tumors  from  the 
start. 

Although  sarcomata  may 
occur  in  any  part  of  the 
h'xly,  there  are  certain  seats 
of  predilection — the  bones, 
the  periosteum,  the  subcuta- 
neous tissues,  the  skin  (pig- 
mented moles),  the  walls  of 
the  blond  and  lymph  vessels  ; 

certain  glandular  orpins — the  parotid  gland,  the  testis,  the  ovary  and  the 
mamma  ;  the  brain,  the  fascia,  and  the  intermuscular  planes  of  connective  I  issue. 
They  are  rarely  primary  in  muscles.  The  retina  and  the  sheaths  of  nerves 
are  occasional  sites.  As  noted  elsewhere,  the  various  benign  connective-tissue 
tumors  may  undergo  sarcomatous  degeneration — fibroma,  lipoma,  chondroma, 
etc. — and  thus  tumors  containing  mixed  element-  are  formed.  The  sarcomata 
themselves  undergo  various  forms  of  degeneration — mucoid  with  the  formation 
of  cysts,   fatty,  caseous,  calcification,  etc. 

Owing  to  the  presence  of  many  thin-walled  vessels,  bleeding  often  takes 
place  into  the  substance  of  the  tumor  or  into  the  cystic  cavities,  and  the  so-called 
malignanl  blood  cyst  is  thus  formed.     When  the  tumor  invade-  the  skin,  ulcer- 


1'ic.  7'.). — Multiple  Sarcomatous  Nodules  in  the  Skin-  of 
the  Trunk.  Inoperable.  (Collection  of  Dr.  Charles  Mo- 
Burney.) 


246 


TUMOKS 


ation,  the  formation  of  large  fungating  masses  of  bleeding  tissue,  and  sloughing 
are  common.  By  growing  into  the  caliber  of  the  veins,  tumor  cells  enter  the 
circulation  and  find  lodgment  in  the  lungs.  If  the  original  growth  were  situ- 
ated in  the  portal  system  the 
lodgment  may  take  place  in  the 
liver.  In  either  case  a  meta- 
static tumor  results.  If  the  in- 
vaded vein  is  large,  consider- 
able tumor  masses  may  break 
off  and  plug  the  pulmonary  ar- 
tery, or  be  caught  in  the  right 
auriculo-ventricular  orifice. 

Sarcoma  may  occur  at  any 
period  of  life ;  it  is  common  in 
infancy,  youth,  and  early  adult 
life,  but  may  appear,  although 
less  often,  in  old  age.  Sarcom- 
ata exhibit  very  varied  degrees 
of  malignancy.  The  more  the 
cellular  elements  predominate 
over  the  intercellular  substance 
the  more  malignant  the  tumor. 
Thus  the  small,  round-celled 
sarcoma,  very  rich  in  cells  and 
poor  in  stroma,  is  an  exceed- 
ingly fatal  form.  They  are 
soft,  rapidly  growing  tumors 
Avhich  rapidly  infiltrate  the  sur- 
rounding tissues  and  produce 
early  metastases.  The  pigmented  or  melanotic  sarcoma  is  also  very  malig- 
nant, and  soon  disseminates  itself  throughout  the  body.  The  harder  forms 
containing  much  fibrous  tissue  and  fewer  cells  (fibro-sarcoma)  are  some  of 
them  almost  on  the  border  line  of  benign  new  growths.  The  sarcomata  which 
occur  in  the  medulla  of  the  long  bones  possess  a  capsule,  and  as  long  as  the 
capsule  remains  unbroken  they  may  be  operated  upon  and  removed  with  a 
fair  prospect  of  cure ;  once  the  capsule  is  destroyed  and  the  tumor  begins 
to  infiltrate  the  surrounding  tissue,  the  prognosis  is  much  worse.  Sarcomata 
are  classified  according  to  the  type  of  cells  they  contain  and  the  relations  of 
the  cells  to  the  intercellular  substance.  Combinations  of  the  various  types 
are  not  uncommon. 

Small  Rotjxd-celled  Sarcoma. — As  already  noted,  small  round-celled 
sarcoma  is  one  of  the  most  surely  and  rapidly  fatal  forms  of  malignant  disease. 
It  is  characterized  by  rapid  growth  and  infiltration  of  the  surrounding  tissues, 
early  dissemination  through  the  veins,  and  the  formation  of  metastases  in  the 


Fig.  80. — Rect~rrext  Sarcoma  of  the  Back.  Inop- 
erable. (Collection  of  Dr.  Charles  McBurney,  Roose- 
velt Hospital.) 


DIAGNOSIS    ()!•'    THE    DIFFERENT    KINDS    OF    TUMORS 


247 


and  elsewhere.  The  tumor  is  soft,  very  rascular;  it-  cut 
section  is  while,  and  resembles  brain  tissue  in  appearance.  When  squeezed,  a 
milky  white  juice  can  be  expressed  from  it-  surface.  Microscopically ,  il  con- 
sists of  a  fine  reticular,  granular,  or  homogeneous  stroma,  small  in  quantity, 
in  which  lie  embedded  innumerable  small  round  cells  with  a  large  nucleus  and 
a  small  quantity  of  protoplasm.  These  cells  resemble  a  white  blood  cell,  and 
some  of  them  -how  ameboid  movement.-.  The  blood-vessels  are  numerous,  and 
their  walls  so  ihin  as  to  .-.rein  to  he  formed  merely  of  tumor  cells.  The  cells 
may   be  evenly  distributed 

throughoul  the  stroma  when 

the  structure  resembles  that 
of  a  lymph  gland,  or  a 
fibrous  stroma  containing 
alveoli  of  various  shapes 
ami  sizes,  filled  with  cells, 
may  give  the  tumor  an  al- 
veolar character  (alveolar 
sarcoma).  The  structure 
may  he  that,  in  other  words, 
of  carcinoma. 

Large  Rouxd-celled 
Sarcomata. — Sarcomata  of 
this  type  possess  large  glob- 
ular, nucleated  cells,  and 
a  structure  similar  to  the 
small-celled  variety.  They 
are  not  quite  so  malignant 
as  the  small-celled  type,  but 
their  mode  of  growth  and 
the     effects     produced      are 

quite  similar.   Round-celled 

sarcoma  originates  in  many 
tissues  and  organs:  bone, 
periosteum,  muscles,  fascia, 
tendons,  lymph  glands,  con- 
nective tissues  generally, 
the  brain,  spinal  cord, 
ovary,  testis,  the  eye,  and 
in  many  other  situation-. 
They  may  occur  during  any 
period  of  li fe  from  infancy 
to  old  age. 

A   variety  of  round-celled  sarcoma  is  known  as  lymphosarcoma,  from  the 
resemblance  of  their  tissue  to  thai  of  a  lymph  gland.     They  occur  most  often  in 


Fig.  81. — Recurrent  Sarcoma  of  ttie  Shoulder,  Showing 
a  Characteristic  SUPERFICIAL  NODtTLE  of  SARCOMATOUS 
Tissue  which  had  Undergone  Ulceration. 
Note. — The  case  presented   itself  as   a   fracture  near  the 
upper  end  of  the  humerus,  the  result  of  very  slight  violence. 
Soft  crepitation   and   the  formation  of  a  larsje  hematoma  in 
the  region  of  the  shoulder  and  upper  arm  led  to  the  suspicion 
of  sarcoma.       Incision  showed  the  upper  third  of  tlie  humerus 
infiltrated  with  sarcomatous  tissue.     Amputation  having  be  p 
refused  the  diseased  tissues  weir  removed  as  far  as  was  practi- 
cable; but,  as  shown  in  the  picture,  recurrence  soon  took  place 
and  destroyed  the  patient's  life.      (Collection  oi  Dr.  Charles 
RdcBurney,  Roosevelt  Hospital.) 


248 


TUMOES 


young  persons,  and  their  favorite  situations  are  said  to  be  the  base  of  the 
tongue  and  the  larynx,  the  tonsils,  the  testes,  the  superior  mediastinum,  the 

subpleural  and  subperitoneal 
tissues  (Sutton).  They  do  not 
differ  in  malignancy  from  the 
ordinary  small-celled  form. 

Spindle-celled  Sarco- 
ma.— The  cells  are  long  and 
slender  and  fusiform.  The 
amount  of  protoplasm  may  be 
small  compared  with  the  size 
of  the  nucleus.  These  cells 
tend  to  arrange  themselves  in 
parallel  bundles,  running  in 
various  directions,  and  may 
be  hard  to  distinguish  from 
fibrous  tissue.  The  presence 
of  numerous  large  nuclei  is 
suggestive  of  sarcoma.  In 
other  cases  the  cells  possess 
abundant  protoplasm,  and 
may  exhibit  transverse  stria- 
tions  like  muscle  fibers.  Some- 
times spindle-celled  sarcoma 
contains  an  abundant  quan- 
tity of  ordinary  white  fibrous 
tissue ;  the  tumor  is  then  known  as  fibrosarcoma.  Many  spindle-celled  sar- 
comata contain  sarcoma  cells  of  other  types — stellate,  giant,  or  other  forms 
of  cells — and  sometimes  pieces  of  cartilage,  bone,  or  muscle. 

"  The  spindle-celled  sarcomata  arise  especially  in  periosteum  and  secreting 


Fig.  82. — Sarcoma  of  the  Skin  on  the  Inner  Aspect  of 
the  Knee-joint,  Ulcerated.  Duration  of  tumor  six 
months.  (Collection  of  Dr.  Charles  McBurney,  Roose- 
velt Hospital.) 


Fig.  83. — Sarcoma  of  Great  Toe;  Female  Patient  Aged  Fifty-five.     Operative  cure,  subsequent 
history  not  known.     (Collection  of  Dr.  Charles  McBurney,  Roosevelt  Hospital.) 


DIAGNOSIS    OF   THE    DIFFERENT    KINDS    OF    TUMORS 


249 


glands,  such  as  the  ovary,  testis,  parotid,  kidney,  and  mamma  "  '  Sutton  }.  They 
are  less  malignant  than  the  round-celled  variety;  they  do  not  gro\*  as  rapidly 
nor  do  they  form  metastases  al  bo  early  ;i  period.  Sarcomata  containing  stellate 
cells  are  usually  found  combined  with  myxoma  and  chondroma.  The  stellate 
cells  are  branched,  ;m<l   possess  fine  intercommunicating   proc<  They  lie 

in  a  soft  mucoid  basement  substance.  The  alveolar  sarcoma  "  is  made  up  of 
mononuclear  and  polynuclear  cells,  as  ;i  rule  aboul  as  Large  as  average  pave- 
ment epithelial  cells,  which  lie  singly  <»r  in  groups  in  a  fibrous,  less  often  in 
a  homogeneous  intermediary  sub- 
stance. A  characteristic  feature  of 
this  variety  is  that  the  cells,  con- 
trary to  carcinoma,  are  closely 
united  to  the  connect  ive-tissuc  stro- 
ma, and  cannot  be  easily  separated 
from  the  fibrous  meshes.  Although 
this  forms  the  means  of  distinguish- 
ing the  alveolar  sarcoma  from  car- 
cinoma, yet  sections  of  the  two  tu- 
mors under  the  microscope  often 
present  such  similar  pictures  that 
it  is  very  ditlicult  to  recognize  one 
from  the  other"  (Tillmanns). 

Plexifoem  Angiosarcoma. — 
This  form  of  sarcoma  originates 
from  sarcomatous  degeneration  of 
the  walls  of  the  blood  and  lymph 
vessels  in  an  angioma.  Both  the 
endothelia  of  the  vessel  sheath  and 
the  endothelia  lining  the  interior  of 
the  vessel  itself  undergo  prolifera- 
tion. I)y  a  hyalin  degeneration  of 
the  walls  of  the  vessels  a  picture  is 
presented  of  hyalin  cylinders  in- 
closing columns  of  cells. 

Tf  the  vessel  sheath  and  the  endothelia  of  the  intima  of  the  vessel  both 
degenerate,  the  picture  is  that  of  columns  of  hyalin  material  inclosed  by  the 
undegenerated  cells  of  the  sheath.  Formerly  this  peculiar  and  rather  beautiful 
tumor  was  known  as  a  cylindroma]  at  presenl  ii  is  spoken  of  as  an  endothelio- 
saropma,  or  endothelioma.    These  tumors  have  been  especially  studied  in  recent 

years  by  Yolkmann  and  by  Kiister,   Manasse,  and  others.      They  are  sometimes 
malignant,  tumors  which  recur  after  removal  and  invade  the  surrounding  tis 
through  the  lymphatics  much  as  do  carcinomata;  the  path   from  the  primary 
to  the  secondary  tumors  can  sometimes  be  traced  by  the  naked  eye.     They  are 
said  to  be  of  fairly  frequent  occurrence.     A  peculiarity  of  the  endotheliomata 


Fig.  S4. — Mediastinal  Lymphosarcoma.  I*ys]>- 
nea,  dilated  veins,  edema  of  arms,  widespread 
metastases.  Heath  from  pressure  upon  the  in- 
trathoracic organs.     (New  York  Hospital  Medical 

Service,  collection  of  Dr.  L.  A.  Connor.) 


250 


TUMOES 


Fig.  85. — Recurrent  Sarcoma  of  Upper  Jaw  and 
Orbit.  Inoperable.  Four  operations  were  done 
on  this  case,  but  the  tumor  always  returned  and 
finally  ended  the  patient's  life.  (Collection  of 
Dr.  Charles  McBurney,  Roosevelt  Hospital.) 


is  that  the  endothelia  of  the  vessels  may  undergo  'degeneration  before  any 
appreciable  tumor  is  formed.  Such  degeneration  may  lead  to  the  formation 
of  a  hematoma ;  following  this  there  may  develop  a  rapidly  growing  and  malig- 
nant sarcoma.  These  tumors  occur 
most  often  in  the  kidney,  sometimes 
in  the  pleura  or  lung,  and  occasion- 
ally in  other  situations.  They  are 
believed  to  arise  more  often  from 
the  endothelia  of  the  lymph  vessels, 
sometimes  from  the  outer  layer  of 
the  vascular  sheaths  of  the  blood- 
vessels, rarely  from  the  endothelia 
lining  the  blood-vessels.  They  occur 
partly  as  distinct  tumors  and  partly 
in  combination  with  various  forms 
of  sarcoma.  Some  of  these  tumors 
remain  encapsulated,  and  are  only 
moderately  malignant,  or  even  be- 
nign ;  others  run  a  course  closely 
resembling  that  of  carcinoma,  as 
already  noted. 

A  peculiar  form  of  endothelioma 
is  known  as  xanthoma.  It  occurs  as 
flat  or  rounded  nodules  in  the  skin,  sometimes  single  and  sometimes  multiple, 
and  characterized  by  a  peculiar  sulphur-yellow  color  due  to  a  deposit  of  fat  in 
the  cells.  It  is  prone  to  appear  where  folds  of  skin  lie  in  contact,  notably  in 
the  axilla,  neck,  groin,  and  other  situations.  The  disease  is  sometimes  a  com- 
plication of  diabetes,  and  it  is  said  that  the  nodules  sometimes  undergo  sar- 
comatous degeneration. 

Melano-sarcoma — Pigmented  Sarcoma. — This  is  one  of  the  most  malig- 
nant forms  of  tumor.  It  is  characterized  by  a  deposit  of  pigment  of  a  brown 
or  black  color  in  the  tumor  cells,  sometimes  in  the  intercellular  substance.  The 
cells  are  commonly  round,  spindle-shaped,  or  branched.  In  a  good  many  cases 
the  tumor  is  of  the  alveolar  type.  They  frequently  originate  where  pigment 
already  exists,  as  in  pigmented  moles.  They  are  characterized  by  an  extraor- 
dinarily rapid  dissemination  to  distant  parts  of  the  body.  The  pigmented  spot 
upon  the  skin  becomes  larger,  and  begins  to  form  a  tumor  which  rapidly  in- 
creases in  size.  In  some  cases,  before  the  original  growth  has  attracted  serious 
attention  dissemination  has  already  occurred.  The  favorite  sites  for  the  devel- 
opment of  melano-sarcoma  are  beneath  pigmented  moles,  notably  those  which 
are  hairy,  beneath  the  finger  nails  and  toe  nails,  elsewhere  on  the  extremities, 
and  in  the  neighborhood  of  the  amis  and  vulva.  They  occur  also  in  the  choroid 
coat  of  the  eye,  more  rarely  in  the  ciliary  body.  They  early  infect  the  neigh- 
boring lymphatic  glands. 


DIAGNOSIS    OF    THE    DIFFERENT    KINDS    oi-    TUMORS 


25  I 


/ 


Sometimes  the  dissemination  appears  n>  be  more  thai  of  some  pigment- 
producing  substance  than  "l"  tumor  cells.  The  urine  may  be  deeply  pigmented 
i  melanuria  |.  The  urine,  when  firsl  passed,  may  be  clear,  and  after  a  few  hours 
may  turn  as  black  as  ink.  The  secondary  deposits  take  place  in  the  skin, 
producing  visible  pigmented  tumors;  In  the  lungs,  in  the  liver,  and,  in  fact,  in 
any  of  the  tissues.  Examination  of  tin-  bodies  of  patients  dead  of  this  disease 
may  show  an  extensive  deposil  of  pigmenl  in  all  the  tissues.  Pigmented  tumor- 
may  lie  found  in  the  internal  organs  an. I  elsewhere,  and  the  cul  surfaces  "t" 
the  solid  viscera  and  of  the  bones  may  appear  as  though  they  had  been  rubbed 
with  Borne  dark-brown  or  black  pigment  The  disease  rarely  occurs  in  child- 
hood, ami  the  greatest  aumber  <>t'  cases  occur  during  middle  lif*-. 

Chloeoma. — Chloroma  is  a  form  of  round-celled  sarcoma  originating  usu 
ally  in  the  periosteum  of  the  bones  of  the  la-ad  and  face,  and  producing  second- 
ary  nodules  in  the  internal  organs  by 
metastases,  and  characterized  by  a  pe- 
culiar pale  grass  or  brownish-green  color 
due  to  the  presence  in  the  cells  of  the 
tumor  of  numerous  highly  refractive 
granules  which  give  the  chemical  reac- 
tions of  t'at. 

General  Characters  of  Sarcoma. 
—  From  the  preceding  statements  in  re- 
gard to  the  different  kinds  of  sarcoma  it 
is  scarcely  necessary  to  repeat  that  it  is 
in  general  a  terrible  and  deadly  disease. 
The  early   diagnosis   and    operative   re- 
moval   through   healthy   tissues,   and   at 
a  distance  from   the  disease,   offers   the 
only    possible   hope   of  cure.      Unfortu- 
nately, sarcoma  is  not  in  general  a  pain- 
ful   disease    in    its    early    stages,    and    these    tumors    may,    when    situated    in 
positions  not  easily  accessible  to  sight  and  touch,  entirely  escape  the  notice  of 
the  patient  until  they  have  existed  for  some  time  and  have  attained  a  consid- 
erable  size. 

Certain  general  characters  of  sarcoma  are  here  recapitulated:  Origin  in 
connective  tissue.  Generally  tumors  of  rapid  growth.  Early  they  are  encap- 
sulated; later  they  infiltrate,  in  the  worst  forms  almosl  from  the  start.  The 
softer  tin-  consistence  of  the  tumor  and  the  more  rapid  the  growth,  the  worse 
the  prognosis.  Owing  to  degenerative  changes,  cyst  formation,  hemorrhage, 
and  the  composite  character  of  the  tissues  they  contain,  sarcomata  are  often  of 
uneven  consistence,  hard,  soft,  and  fluctuating  areas  alternating  in  the  same 
tumor. 

Differential  Diagnosis  between  Sarcoma  \\i>  Carcinoma.  Sarcom- 
ata <h>  not  tend  to  involve  the  skin  as  early  a-  carcinomata,  and  enormous 


Fig.  86. — Sarcoma  of  the  Vulva  Simulat- 
ing Hernia.     (Collection   of   Dr.  Charles 

.MrBurney,  Roosevelt  Hospital.) 


252  TUMORS 

comata  may  be  covered  by  thinned  but  unbroken  skin.  Carcinoma  early  infects 
the  lymph  nodes ;  sarcoma  is  disseminated  usually  through  the  blood  current. 
Lymphatic  infection  is  present  only  in  the  later  stages ;  exceptions  occur — 
melanotic  sarcoma.  The  very  vascular  forms  may  pulsate.  As  long  as  they 
remain  encapsulated  they  may  be  movable  on  the  surrounding  tissues.  Irregu- 
lar fever  occurs  in  the  rapidly  growing  forms  without  ulceration ;  this  is  not 
the  case  with  carcinomata ;  they  do  not  undergo  sclerotic  changes  of  the  base- 
ment substance,  hence  the  puckered  condition  of  the  skin  often  seen  over  car- 
cinoma is  absent. 

Anemia. — No  definite  data  exist  whereby  a  differential  diagnosis  between 
carcinoma  and  sarcoma  can  be  made  from  blood  changes ;  both  are  usually 
attended  by  diminution  of  red  cells  and  hemoglobin  in  their  later  stages.  In 
the  individual  cases  marked  differences  occur,  owing  to  complications  and 
accidental  conditions.  Hemorrhage,  mechanical  interference  with  the  ingestion 
and  digestion  of  food,  ulceration,  and  pyogenic  infection,  or  their  absence,, 
largely  determine  the  grade  of  anemia  in  both  forms  of  tumor.  Leucocytosis 
is  more  regularly  present  in  uncomplicated  cases  of  sarcoma  than  in  carcinoma. 
The  more  rapidly  growing  and  malignant  forms,  small  round-celled  and  melan- 
otic sarcoma,  show  a  higher  leucocyte  count  than  others.  The  polynu  clear  cells 
are  usually  in  excess.  Eosinophilia  is  believed  by  Mensser  to  be  a  diagnostic 
sign  of  value  in  sarcoma  of  the  medulla  of  the  bones  (Ewing).  Sarcoma  may 
occur  at  any  time  of  life,  but  is  frequent  in  youth.  Carcinoma  regularly 
develops  during  middle  life  or  later ;  is  rare  in  youth.  Sarcoma  is  often  pain- 
less in  its  early  stages.  Carcinoma  is  usually  accompanied  by  more  or  less 
pain  of  lancinating  character. 

The  Epithelial  Tumors 

Epithelial  tumors  are  derived  from  the  outer  and  inner  embryonic  layers: 
epiblast  and  hypoblast.  They  originate  in  skin,  mucous  membrane,  and  glandu- 
lar organs  possessing  epithelium.  They  include  papilloma,  adenoma,  carci- 
noma, and  epithelioma. 

Papilloma. — Papilloma  occurs  upon  the  skin  and  mucous  membranes.  The 
tumor  consists  of  a  localized  hypertrophy  of  the  normal  tissue  elements — epi- 
thelium, connective  tissue,  and  blood-vessels.  There  are  two  varieties  to  be 
distinguished:  the  hard  and  soft  papilloma. 

Hard  Papilloma  (Verruca). — Warts. — Small,  hard  elevations,  with  a 
smooth  or  uneven  surface ;  in  size  varying  from  a  pin's  head  to  a  quarter  of  an 
inch  in  diameter;  white  or  pink  in  color,  occasionally  pigmented.  They  consist 
of  a  base  of  fibrous  tissue  containing  blood-vessels  and  surmounted  by  a  variable 
number  of  layers  of  horny  epithelium.  They  occur  upon  the  general  integu- 
ment, most  often  upon  the  dorsal  surface  of  the  hand  and  fingers;  are  often 
multiple.  They  are  common  among  children.  They  are  neither  painful  nor 
tender,   unless   irritated   mechanically.      The   papillary   outgrowths   from   the 


DIAGNOSIS    OF   THE    DIFFERENT   KINDS    OF    TUMORS 


253 


surface  may  give  the  wart  a  mulberry  appearance — vulgarly  a  "  seed  wart." 
They  are  believed  to  be  inoculable.  Hyperplasia  of  the  horny  layers  of  epi- 
thelium affects  the  toe  nails  in  certain  instances,  usually  the  great  toe  nail. 
The  cases  I  have  seen  were  old  women  of  the  laboring  classes,  often  bedridden 
and  dirty;  the  nails  were  greatly  thickened  and  elongated,  sometimes  a  half 
inch  thick  and  two  inches  in  length,  often  curved  upward  over  the  toe  (ony- 
choma). Similar  horny  outgrowths,  cutaneous  horns,  may  take  place  from 
the  general  integument  of  the  forehead,  trunk,  and  extremities;  rarely  they 
are  multiple.  These  horns  may  reach  several  inches  in  length.  They  occur 
chiefly  in  old  people,  and  may  arise  from  cutaneous  atheromata  (sebaceous 
cysts).  In  young  persons  a  combination  with  angioma  may  occur  upon  the 
dorsal  surfaces  of  the  fin- 
gers and  toes.  The  base 
of  a  cutaneous  horn  may 
be  the  starting  point  of 
epithelioma. 

Clavus. — Corns  of  the 
hard  and  soft  variety  are 
hyperplasias  of  the  horny 
layer  of  the  epidermis  of 
the  toes  or  sole  of  the  foot. 
They  usually  arise  from  the 
continued  pressure  of  a  bad- 
ly fitting  boot.  They  are  too 
well  known  to  require  a  long 
description. 

Soft  Papilloma. — 
Ac  am  inate  Warts. — These 
occur  usually  at  the  muco- 
cutaneous junctions  of  the 
vulva  and  anus  and  upon 
the  prepuce.  They  occur 
spontaneously  or  as  the  re- 
sult of  irritating  discharges 
from  the  urethra   or  vulva. 

Thev   have    a   framework   of         Fig.  87. — Vert  Extensi-vz  Soft  Papillomata  of  the  Pexis, 
~  "  ni  .  .,  Simulating  Malignant  Epithelioma.     Cured  bv  opera- 

SOlt  llbrOUS  tiSSUe,   are  quite  tion.     (Author's  collection.) 

vascular,    and    are    covered 

by  a  rather  soft,  thin  epithelium.  They  are  often  multiple,  sessile,  or 
pedunculated,  and  may  form  a  cauliflower  growth  of  considerable  size.  They 
are  pink  or  red  in  color,  soft,  tender,  and  sensitive.  When  numerous  and 
large  they  become  macerated  in  the  secretions  of  the  skin,  and  eroded.  They 
are  then  bathed  in  a  yellow,  creamy  discharge  of  most  offensive  odor;  the 
eroded  surface  becomes  infected  with  pyogenic  organisms,  and  may  ulcerate. 


254  TUMORS 

Under  these  conditions  they  may  be  mistaken  for  cancer  of  the  penis.  I  have 
seen  cases  in  which  the  papillomatous  masses  would  have  filled  a  teacup.  Soft 
papilloma  occurs  as  a  polypoid,  soft,  or  warty  tumor  upon  the  mucous  mem- 
brane of  the  larynx,  cervix  uteri,  bladder,  and  rectum,  and  other  mucous  mem- 
branes.    They  may  undergo  malignant  degeneration. 

Villous  Tumor  of  the  Bladder  and  Pelvis  of  the  Kidney. — This  is  an  in- 
teresting form  of  pajDilloma.  The  tumor  is  common  in  the  bladder,  more  rare 
in  the  kidne}\  It  consists  of  a  delicate,  branching  growth  of  slender  processes 
containing  a  connective-tissue  framework  of  delicate  blood-vessels  and  a  thin 
covering  of  epithelium.  The  symptoms  produced  by  these  tumors  are  chiefly 
pain  and  bleeding,  often  of  a  serious  character.  They  may  be  diagnosticated 
by  the  cystoscope,  by  the  passage  of  portions  of  the  tumor  with  the  urine,  and  by 
the  bleeding  in  the  absence  of  other  causes.     (See  Regional  Surgery,  Bladder.) 

Molluscwn  contagiosum — Molluscum  epitheliale. — A  rather  uncommon  dis- 
ease, which  usually  occurs  among  children  in  orphan  asylums,  etc.,  in  epidemics. 
Solitary  cases  are  not  common.  The  disease  affects  particularly  the  scrotum, 
sometimes  the  face,  and  is  contagious.  Small  white,  waxy-looking  nodules 
appear  in  the  superficial  layers  of  the  skin,  varying  in  size  from  that  of  a 
pea  to  that  of  a  hazel  nut ;  they  slowly  increase  in  size,  and  may  become 
pedunculated ;  in  the  center  of  the  surface  of  the  nodule  a  small  yellow  or 
dark-colored  speck  can  be  seen — the  opening  of  a  sebaceous  follicle.  If  the 
tumor  is  squeezed  a  mass  of  caseous  material  is  extruded,  containing  swollen 
epithelial  cells  and  bodies,  regarded  by  some  authorities  as  the  psorosperms, 
or  coccidia  of  a  fungus — the  supposed  cause  of  the  affection. 

Adenoma. — Glandular  tumors  having  the  structure  of  a  secreting  gland. 
They  consist  of  a  fibrous  stroma,  containing  tubules  and  alveoli  lined  with 
glandular,  cubical,  or  other  epithelium ;  sometimes  they  have  the  structure  of 
an  acinous  gland.  When  the  stroma  is  in  excess,  and  the  cells  are  few,  the 
tumor  is  called  a  fibro-adenoma.  Sometimes  tubules  and  acini  become  greatly 
dilated  from  retained  secretion  with  the  formation  of  cystic  cavities — cysto- 
adenoma  of  breast,  cysto-thyroid  or  bronchocele,  multilocular  ovarian  cyst. 
Adenomata  are  generally  nodular,  encapsulated  tumors  of  firm  or  soft  con- 
sistence, movable  in  the  surrounding  tissues,  of  slow  growth,  and  not  painful. 
They  are,  however,  prone  to  undergo  cancerous  degeneration;  the  cells  pro- 
liferate, invade  the  stroma,  finally  perforate  the  capsule  and  invade  the  sur- 
rounding tissues,  and  become  adeno-carcinomata.  There  are  forms  of  adenoma 
which  form  metastases,  and  recur  after  removal  without  undergoing  this  can- 
cerous change;  such  are  the  malignant  adenomata  of  the  rectum.  (See  also 
Tumors  of  the  Thyroid  Gland.)  Adenomata  occur  especially  in  glandular 
organs — the  mamma,  the  kidney,  the  liver,  the  thyroid  gland,  the  respiratory 
tract,  the  alimentary  canal,  the  genital  organs,  ovary,  testis,  skin  (arising 
from  •sebaceous  glands  and  sweat  glands).  They  are  rare  in  the  submaxillary 
and  sublingual  glands,  common  in  the  prostate  and  parotid.  They  occur  in 
the  pituitary  body. 


DIAGNOSIS   ()K   THE    DIFFERENT    KINDS    OF   TUMORS 


255 


A.s  already  indicated,  adenomata  vary  greatly  in  size.  In  the  skin  they 
may  I"'  only  the  size  of  :i  pea;  in  the  breast,  tli<'  size  oi  n  fist;  in  the  ovary 
they  may  occupy  nearly  the  entire  abdominal  cavity  and  weigh  many  pounds. 
The  greater  number  of  adenomata  occur  during  youth  and  early  adull  life. 
They  may,  however,  occur 
later,  as  in  the  prostate. 
The  adenomata  undergo  cys- 
1  ic  and  carcinomatous  degen- 
eration. Villous  papillom- 
ata  may  form  on  the  walla 
of  the  cystic  varieties.  In 
large  cvstic  adenomata  of 
the  ovary  calcareous  degen- 
eration is  not  uncommon. 
Lasl  year  I  removed  a  large 
tumor  of  this  kind,  growing 
from  the  ovary,  which  con- 
tained calcareous  plaques  as 
large  and  as  thick  as  a  man's 
hand.  The  adenomata  arc 
usually  benign,  do  not  recur 
after  operation  nor  infect 
the  organism.  The  symp- 
toms arc  usually  mechanical, 
as   pressure  upon  the   brain 

ill   adenoma    Of   the    pituitary        Fra.  88. — Adenoma  of  the  Bhkast.     Observe  that  tin- tumor 
.        .  _  .  .    .  is  prominent,    has   a  sharply  marked   hinder  and   that   the 

body.      Interterence  With  uri-  nipple  is  not  retracted.     (Author's  collection.) 

nation    in    adenoma    of   the 

prostate;  deformity  and  pressure  symptoms  in  the  thyroid  gland,  the  same  in 

large  tumors  of  the  ovary. 

Carcinoma. — Carcinoma  is  a  tumor  originating,  like  adenoma,  in  epithelial 
structures.  The  general  arrangement  of  the  tissue  is  that  of  a  glandular 
organ,  but  imperfectly  and  abnormally  developed.  There  is  a  fibrous  stroma 
containing  alveoli;  the  alveoli  contain  cells  of  the  epithelial  type  arranged 
more  or  less  irregularly  in  groups  or  masses  lining  or  filling  the  alveoli;  gen- 
erally the  cells  depart  in  size,  shape,  and  arrangement  from  normal  glandular 
epithelium.  They  possess,  however,  an  extraordinary  power  of  proliferation. 
They  infiltrate,  displace,  and  destroy  the  normal  tissue  elements  of  the  vicin- 
ity. This  process  goes  on  indefinitely.  The  tumor  cells,  moreover,  outer  the 
lymph  channels,  and  are  carried  to  and  lodge  in  the  lymph  node-,  there  to 
multiply  and  produce  new  tumors.  Eventually  tumor  cells  find  their  way 
into  the  blood  current,  and  thus  dissemination  throughout  the  organism  results, 
new  tumors  are  formed  in  various  situations. 

Carcinoma  also   invades  the  overlying  skin   and    produces  ulceration.      The 


256  TUMORS 

ulcer  is  of  irregular  shape.  Its  edges  are  hard  aud  adherent  to  the  deeper 
tissues.  The  base  has  an  unwholesome  appearance,  sometimes  sloughy,  some- 
times covered  with  vascular,  fimgating  masses  of  tumor  tissue.  In  the  softer 
varieties  of  carcinoma  rich  in  cells,  a  fimgating  bleeding  mass  of  tumor  tissue 
may  sprout  up  above  the  level  of  the  surrounding  skin,  and  grow  with  ex- 
traordinary rapidity.  Degenerative  processes  regularly  occur  in  carcinomata, 
notably  fatty  degeneration  of  the  tumor  cells,  ending  in  necrosis  and  slough- 
ing of  the  older  portions  of  the  growth,  while  new  structures  are  continually 
being  invaded  at  the  periphery. 

Cystic,  calcareous,  and  myxomatous  degeneration  also  occur  in  carcinoma 
as  well  as  hemorrhages  into  the  substance  of  the  tumor.  The  tendency  of 
the  connective-tissue  stroma  of  carcinoma  to  contract  as  an  accompaniment 
to  the  atrophy  and  absorption  of  the  cellular  elements  of  the  tumor  has  already 
been  noted;  the  characteristic  retraction  and  puckering  of  the  skin  covering 
cancers  is  thus  produced.  Cancer  is  always  an  infiltrating  tumor,  its  very 
mode  of  growth  precludes  the  continued  presence  of  a  capsule.  Cancer 
occurs  primarily  only  in  tissues  containing  epithelium;  the  skin  and  its  acces- 
sory sebaceous  and  sweat  glands,  mucous  membrane,  and  glandular  organs, 
including  the  entire  gastro-intestinal  tract,  the  mamma,  ovary,  testis,  thyroid, 
prostate,  pancreas,  the  liver,  the  biliary  passages,  the  parotid,  the  mucous 
glands  of  the  cervix  uteri,  etc.  The  production  of  cancer  in  places  subjected 
to  chronic  irritations  and  in  scars  and  ulcerations  (especially  tubercular  and 
syphilitic)  has  already  been  noted.  Cancer  may  also  follow  a  single  trauma- 
tism.    Benign  tumors  may  undergo  cancerous  degeneration. 

Cancer  is  inoculable.  Experimentally  cancer  can  be  inoculated  success- 
fully on  the  body  of  one  already  suffering  from  cancer,  for  example,  from 
a  cancerous  breast  to  the  other  breast.  The  mucous  membrane  of  the  cheek 
is  sometimes  inoculated  from  cancer  of  the  tongue,  etc.  Rarely  this  hap- 
pens from  one  individual  to  another.  Cancer  of  the  penis  has  been  observed 
in  the  husband  of  a  woman  suffering  from  cancer  of  the  cervix  uteri.  AVhile 
it  is  quite  probable  that  in  the  near  future  the  parasitic  nature  of  cancer  will 
be  demonstrated  by  isolation  and  successful  inoculation  of  a  cancer  germ  or 
fungus,  as  yet  the  existence  of  organisms  in  cancer  cells  cannot  be  said  to 
have  a  diagnostic  significance. 

The  regular  course  of  carcinoma  ends  in  the  death  of  the  individual  from 
dissemination  of  the  tumor,  and  the  production  of  cancerous  cachexia,  from 
hemorrhage,  chronic  sepsis,  and  exhaustion,  or  in  other  cases  from  starva- 
tion, as  when  the  tumor  is  so  situated  that  the  ingestion  or  assimilation  of 
food  is  prevented,  cancer  of  the  esophagus,  pyloric  end  of  the  stomach,  intes- 
tinal obstruction  in  cancer  of  intestine;  asphyxia,  when  the  tumor  presses 
upon  the  trachea,  the  larynx,  or  the  bronchi,  etc.  In  fact,  any  and  every 
bodily  function  necessary  to  life  may  be  impaired  and  destroyed  in  the  course 
of  the  disease.  The  duration  of  life  varies  from  a  few  months  to  many  years. 
The  softer  the  tumor,  the  richer  in  cells  and  poorer  in  fibrous  stroma;  the 


DIAGNOSIS   OF   THE    DIFFERENT    KINDS    OF   TUMORS         257 


more  rapid  its  growth,  the  earlier  tin  formation.of  metastases  and  the  devel- 
opment of  fatal  lesions.  Od  the  other  band,  a  scirrhous  carcinoma  of  the 
breasl  may  grow  very  slowly,  and  nol  interfere  with  the  general  bealtb  for 
many  years.  The  same  Is  true  of  certain  cancers  of  the  skin  (rodenl  ulcer). 
Histologically,  the  tumor  tissue  bears  a  likeness  to  the  structures  in  which 
it  luis  originated,  and  this  likeness  is  preserved  in  the  secondary  tumors  formed, 
no  matter  where  situated.  We  are  thus  able  to  classify  carcinomata  and 
divide  them  into  several  types. 

The  Superficial  Form  oe  Epithelioma — Skin  Cancer.— This  form  of 
cancel'  originates  in  skin  and  in  mucous  membranes;  in  the  skin,  either  from 
the  squamous  epithelium  of  the  Rote 
malpighii,  or  from  the  glandular 
organs  of  the  skin,  especially  the 
sebaceous  glands.  The  disease  orig- 
inates in  mucous  membranes  covered 
by  stratified  epithelium,  the  mouth, 
the  esophagus,  the  bladder,  the  va- 
gina, etc. 

There  is  a  very  chronic  form  of 
epithelioma  originating,  according 
to  some  observers,  in  the  epithelium 
of  the  Rete  malpighii;  by  others  be- 
lieved to  grow  from  the  glandular 
structures  of  the  skin — the  seba- 
ceous glands,  the  sweat  glands,  the 
hair  follicles,  etc.,  and  commonly 
known  as  rodent  ulcer,  formerly  as 
cancroid.  It  is  characterized  by  a 
very  chronic  course  extending  over 
years,  and  greatly  delayed,  or  ab- 
sence of  constitutional  infection. 
The  lymph  glands  may  remain  un- 
affected throughout  the  disease.     It 

affects  the  skin  of  the  face  in  old  people,  lint  has  been  observed  as  early  as  the 
twenty-fifth  year.  It  begins  upon  the  cheeks,  the  alse  of  the  nose,  the  eyelids, 
the  forehead,  the  ears,  the  scalp,  or  the  neck.  It  may  begin  in  a  wart,  upon  the 
site  of  a  chronic  eczema,  or  originate  de  novo  as  a  firm  rounded  nodule,  or  a 
lial  indurated  plaque  in  the  thickness  of  the  skin.  A  scab  usually  forms  upon 
the  surface,  which  falls  from  time  to  time,  and  finally  leaves  behind  a  super- 
ficial nicer,  which  bleeds  readily.  Upon  inspection  little  white  points  may 
he  noted  upon  the  raw  surface.  By  pressure  these  may  he  extruded  as 
minute  white  spherules  or  columns,  seen  under  the  microscope  to  consist  of 
masses  of  laminated  epithelial  cells,  arranged  in  the  spherules  concentrically. 
They  are  the  so-called  epithelial  "  pearls."  The  ulceration  tends  to  spread 
18 


Fig.  89. — Rodent  Ulcer,  Slowly  Growing  Form 
of  Epithelioma  of  the  Skin  of  the  Neck  Be- 
low the  Ear.     (Collection  of  Dr.  Charles  McBur- 

ney,  Roosevelt  Hospital.) 


258 


TUMORS 


superficially,  and  does  not  invade  the  deeper  structures  for  a  long  time.     This 
is   the   form   of  epithelioma   benefited,    and   sometimes   cured,   by  the   X-rays. 

On  section,  under  the 
microscope,  the  tissue 
is  seen  to  consist  of  an 
alveolar  fibrous  struc- 
ture. The  alveoli  con- 
tain spherical  nests  and 
cylinders  of  epithelial 
cells. 

Untreated,  the  dis- 
ease spreads  slowly  from 
the  periphery,  and  soon- 
er or  later  begins  to  in- 
vade the  deeper  struc- 
tures ;  one  after  another 
the  features  may  be 
slowly  eaten  away.  The 
eye,  the  nose,  the  lips, 
the  cheeks,  etc.,  are  de- 
stroyed, until  the  most 
horrible  deformities  re- 
sult. The  disease  is 
not  necessarily  painful, 
and  constitutional  in- 
fection does  not,  as  a 
rule,  occur.  This  very  chronic  form  of  epithelioma  is  to  be  sharply  differ- 
entiated from  the  ordinary  malignant  epithelioma,  such  as  we  see  so  commonly 
on  the  lip,  penis,  and  elsewhere. 

The  Infiltrating  Form  of  Epithelioma. — In  this  form  an  indurated 
nodule  appears,  which  ulcerates,  and  rapidly  infiltrates  the  surrounding  tissues. 


Fig.  90. — Epithelioma  of  the  Ankle  Growing  upon  an  Old  Ul- 
cer.    (Collection  of  Dr.  Charles  McBurney,  Roosevelt  Hospital.) 


Fig.  91. — Epithelioma  on  the  Dorsum  of  the  Hand  which  Grew  in  an  Old  Scar.     Excision  and 
skin-grafting.     Operative  cure.     Subsequent  history  of  patient  unknown.      (Author's  collection.) 


DIAGNOSIS   OF   THE    DIFFERENT    KINDS    OF   TUMORS 


259 


The  edges  of  the  ulcer  are  hard  or  elevated;  the  base  is  dense  and  infiltrated: 
the  surface  is  uneven,  bleed  readily  ;  epithelial  tnassee  can  often  be  recognized 
with  the  naked  eye.  When  such  an  epithelioma  occurs  upon  ;i  mucous 
membrane,  the  surface  is  often  covered  with  papillary  outgrowths  elevated 
above  the  surface.  The  lymph  nodes  soon  become  indurated  and  enlarged, 
;iml   constitutional    infection    follows.      The   diagnosis    of    this    form    of   epi 

thelioma  will  be  more  particularly 
noted  in  the  chapters  on  Regional 
Surgery. 

(  Iylindee-celled  Cabcinoma — 
Adeno-cabcinoma. — Tlii-  form  of 
cancer  originates  in  the  mucous 
membrane  of  the  alimentary  canal 
and  in  the  mucous  membrane  of  the 
uterus.  The  tumors  arc  soft.  The 
stroma  of  the  tumor  is  generally 
small  in  amount  and  the  colls  are 
aliiindanl.  1 1  frequently  undergoes 
myxomatous  degeneration. 


Fig.  92. — Epithelioma  Developing  in  the  Scab     Fio.  03. — Epithelioma    <>k   the    Lower   Lip. 
<>k  an  Amputation  Stump.     (Collection  of  Dr.  The  patienl  was,  as  is  usual  in  these  cases, a 

Charles  McBurney,   Roosevelt   Hospital.)  pipe-smoker.   The  disease  had  existed  for  one 

year.     ( (perative  cure.     (Author's  collection.) 


Glandulab  Cancee — Acinous  Cabcinoma  (Billroth). — This  type  devel- 
ops in  the  several  glandular  organs  of  the  body — the  mamma,  the  testis,  the 
OVary,  the  kidneys,  the  pancreas,  the  liver,  and  other  glands.  The  form  of 
the  cells   and    their  arrangement    vary    according   to   the   organ    in    which   the 


260 


TUMORS 


tumor  originates.  In  the  breast,  for  example,  the  arrangement  of  the  cells 
and  alveoli  resembles,  more  or  less  closely,  an  acinous  gland.  They  form 
nodular,  usually  soft  tumors,  of  rapid  growth,  which  frequently  break  down 
and  ulcerate  (glandular  cancer). 

Carcinoma  Simplex. — By  carcinoma  simplex  or  tubular  cancer  we  under- 
stand a  form  of  cancer  in  which  stroma  and  cellular  elements  are  both  pres- 


Fig.  94. — Scirrhous  Carcinoma  of  the  Breast.     Showing  marked  retraction  of  the  nipple. 
(New  York  Hospital,  service  of  Dr.  F.  H.  Markoe.) 


ent  in  moderate  quantity.  The  alveoli  are  often  small,  sometimes  long  and 
tubular,  sometimes  irregular  in  shape.  The  cells  are  round,  polygonal,  or  oval, 
and  have  lost  their  likeness  to  glandular  epithelium.  The  tumor  is  gener- 
ally of  firmer  consistence  than  is  the  case  with  glandular  cancer. 

The  Carcinomata  are  further  classified  according  to  the  relative  amounts 
of  stroma  and  cellular  elements,  and  according  to  the  character  of  the  cells 
and  the  appearance  of  the  tumor. 


DIAGNOSIS    OF    THE   DIFFERENT   KINDS    OF   TUMORS 


261 


Scirrhus  Carcinoma.— This  tumor  occurs  in  various  situations,  most  com- 
monly in  the  female  breast.  The  amount  of  fibrous  stroma  is  large,  the 
cellular  elements  relatively  few.  It  is  this  form  which  especially  produces 
puckering  of  the  skin  and  re- 
traction of  the  nipple.  These 
tumors  are  characterized  by  ex- 
treme hardness ;  they  feel  as 
hard  as  a  piece  of  wood.  The 
tissue  of  the  tumor  is  so  hard 
that  it  squeaks  when  cut  with  a 
knife.  They  often  cause  ulcer- 
ation of  the  skin,  and  become 
firmly  adherent  to  the  surround- 
ing structures.  In  the  breast 
they  generally  occur  in  old 
women.  Sometimes  the  dis- 
semination is  rapid,  sometimes 
very  slow.  One  sees  scirrhous 
carcinomata  in  the  breasts  which 
have  existed  for  many  years, 
without  causing  general  infec- 
tion. Macroscopically  the  cut 
surface  is  reddish-gray  or  gray- 
ish white  in  color,  and  consists 
mostly  of  dense  connective  tis- 
sue, with  here  and  there  alveoli, 
containing  in  the  older  portions 
of  the  tumor  epithelial  cells, 
which  have  undergone  fatty 
degeneration  and  appear  as 
yellow  specks.  In  the  newer  parts  of  the  growth  the  epithelial  cells  can  still 
be  distinguished  under  the  microscope. 

Medullary  Carcinoma. — A  form  of  carcinoma  containing  a  large  excess 
of  cells  and  a  small  amount  of  fibrous  stroma  is  known  as  Medullary  Car- 
cinoma. The  tumor  is  very  soft,  the  alveoli  are  very  large,  and  the  stroma 
is  thin  and  delicate.  The  tumor  is  exceedingly  malignant.  The  soft  tis- 
sue composing  the  tumor  bears  some  resemblance  to  the  medulla  of  the 
bones  or  to  brain  tissue.  The  medullary  carcinoma  sometimes  grows 
very  rapidly,  forms  a  knobby  soft  tumor,  which  soon  ulcerates  and  forms 
a  fungating  mass  of  bleeding  soft-tumor  tissue.  This  is  one  of  the  forms 
of  malignant  growth  to  which  the  name  fungus  nematodes  was  formerly 
applied.     (See,  however,  Tumors  of  the  Breast.) 

Colloid  Cancer — Carcinoma  Gelatinosum. — In  this  form  of  cancer  the 
fibrous  stroma  and  the  cancer  cells,  one  or  both,  have  undergone  myxomatous 


Fig.  95. — Carcinoma  simplex  of  the  Breast,  Ulcer- 
ated.    (Collection  of  Dr.  Charles  McBurney.) 


262 


TUMORS 


degeneration.  The  tumor  is  composed  of  soft  slimy  tissue.  It  may  originate 
from  an  ordinary  carcinoma  which  has  undergone  mucoid  degeneration,  or  from 
cancerous  degeneration  of  a  myxoma.  It  is  rather  less  malignant  than  ordi- 
nary cancer,  and  is  a  rare  form.  (See  Echinococcus  Multilocularis,  Vol.  II.) 
Occasionally  cancers  are  observed  in  which  the  cells  are  large  and  swollen, 
and  sometimes  true  giant  cells  may  be  observed  in  carcinomata.     Occasionally 


Fig.  96. — Carcinoma  of  the  Femur  and  Knee  Secondary  to  Carcinoma  of  the  Uterus. 

(New  York  Hospital  collection.) 


pigment  is  developed  in  the  cancer  cells,  and  the  rare  tumor  thus  formed  is 
known  as  melano-carcinoma.  The  diagnosis  of  the  different  forms  of  car- 
cinoma will  be  more  particularly  dwelt  upon  in  the  chapters  on  Regional 
Surgery. 

Cystic  Tumors 

As  has  already  been  stated,  cystlike  formations  are  common  in  many 
forms  of  tumors,  benign  and  malignant.  In  addition,  there  occur  cystic 
tumors  of  various  origins;  some  of  them  are  true  new  growths;  some  of  them 
are  due  to  the  retention,  in  glandular  organs  or  in  their  ducts,  of  the  secretory 
products  of  the  gland;  some  of  them  are  due  to  the  presence  in  the  tissues 
of  abnormally  placed  fetal  structures;  some  of  them  are  due  to  inflammatory 
processes  in  preexisting  body  cavities;  they  may  be  due  to  the  growth  in  the 
body  of  various  forms  of  animal  parasites.  Cystic  formations  may  result  from 
traumatisms;  such  are  the  blood  cysts  formed  by  collections  of  blood,  hema- 
tomata,  which  are  not  absorbed. 


DIAGNOSIS    OF   THE    DIFFERENT    KINDS    OF    TUMORS 


263 


Fig.  97. — Sebaceous  Cysts  of  the  Scalp. 
(Collection  of  Dr.  Charles  McBurney.) 


Cysts  Due  to  True  Tumor  Formation. — These  frequently  form  in  adenomata 
when   the  cells   lining   the   tubules   undergo   rapid   proliferation.     The   ducta 
become  dilated,  and   their  cod 
tents  undergo  degeneral  ion,  usu 
ally    mucoid    or   colloid    degen 
eration.       These     tumors     are 
common  in  I  he  ovary ;  the  mul- 
tiple proliferating  cysts  of  the 
ovary  are  tumors  of  this  char- 
acter, and  may  grow  to  a  very 
large  size.     The  single  or  multi- 
ple cystic  tumors  of  I  be  I  byroid 
gland   begin  as  adenomata,  and 
their   degeneration    is    followed 
by   the  production  of  a  cystic 
tumor.        Another     variety     of 
cystic  tumor  occurs  in  connec- 
tion with  the  abnormal  devel- 
opment   of    the    teeth,    as    de- 
scribed under  Odontoma.    They 
cause  dilatation  of  the  inferior 
maxillary  bone,  and  may  attain 

a  large  size.  Some  of  them  are  true  proliferating  tumors,  and  some  of  them 
may  finally  take  on  a  sarcomatous  character  and  recur  after  removal.  Cystic 
formations  also  occur  in  the  long  b.ones;  some  of  them  are  the  result  of  degen- 
erative processes  in  sarcom- 
ata, and  arise  from  myx- 
omatous degeneration  of 
enchondromata,  or  other 
connective-tissue  tumors. 
They  occur  most  commonly 
in  the   femur. 

Retention  cysts  occur 
when,  for  any  reason,  the 
duct  of  a  gland  is  obstruct- 
ed, so  thai  the  secretion  of 
the  gland  cannot  escape. 
The  secret  imi  gradually  ac- 
cumulates, dilate-  the  acini 
of  the  gland,  or  it-  duct, 
until  a  tumor  of  consider- 
able size  may  be  produced. 
The  walls  of  the  sac  are  gradually  distended,  and  by  pressure  the  normal  tissue 
of  the  gland  may  be  gradually  destroyed.     When  such  a  process  take-  place  in 


Fig.  98. — Rare  Congenital  Cyst  of  tiff.   Buttock. 
(New  York  Hospital,  service  of  Dr.  !•'.  W.  Murray.) 


264 


TUMOKS 


an  important  organ,  such  as  the  kidney,  serious  or  even  fatal  results  may  fol- 
low.    (See  Hydronephrosis.) 

Retention  cysts  may  be  divided,  according  to  Virchow,  into  three  classes: 
(1)  Mucous  cysts;  (2)  follicular  cysts;  (3)  retention  cysts  starting  in  the 
secretory  duct  or  the  acini  of  the  large  glands. 

1.  Mucous  Cysts. — Mucous  cysts  arise  from  the  stoppage  of  the  duct  of  a 
mucous  gland.     They  occur  wherever  mucous  glands  exist — as  in  the  uterus,  the 

digestive  tract,  the  mouth, 
the  mucous  membrane  lin- 
ing the  accessory  cavities  of 
the  nose — notably  in  the  an- 
trum of  Highmore. 

2.  Follicular  Cysts. — 
The  sebaceous  cysts  or  wens 
are  a  common  example  of 
this  form.  They  arise  from 
the  retained  secretion  of  a 
sebaceous  gland  connected 
with  a  hair  follicle.  Such 
cysts  also  form  in  sebaceous 
glands  where  no  hair  exists 
— as  in  the  corona  of  the 
penis  and  the  labium  minus. 
They  vary  in  size  from  mi- 
nute dots  no  larger  than  a 
millet  seed  to  tumors  as 
large  as  a  hen's  egg,  or  even 
larger.  When  these  cysts 
are  of  minute  size  and  oc- 
cur in  the  duct  of  the  gland, 
they  constitute  the  so-called 
comedones,  or  black  heads, 
occurring  upon  the  nose  or  cheeks.  When  larger  they  are  retention  cysts  of  the 
gland  itself — smooth,  rounded  tumors  beneath  the  skin.  They  feel  elastic,  and 
are  adherent  at  one  point,  at  least,  to  the  skin,  although  not  to  the  subcutaneous 
tissues.  Upon  minute  inspection  a  little  orifice  can  usually  be  detected  upon 
the  surface  of  the  tumor,  from  which  the  contents  of  the  sac  can  in  many 
instances  be  expressed.  They  contain  a  soft,  white,  crumbly  material,  con- 
sisting of  epithelium,  fat,  and  cholesterin.  Sometimes  the  contents  of  these 
cysts  undergo  partial  decomposition,  with  an  offensive  odor.  They  are  very 
commonly  situated  upon  the  scalp.  They  have  a  fairly  thick  fibrous  wall, 
which  sometimes  becomes  infected  and  suppurates.  Under  such  circumstances 
the  cyst  may  burst  externally  and  produce  exuberant  granulations.  Such  an 
inflamed  cyst  may  be  mistaken  for  epithelioma.     Sebaceous  cysts  are  frequently 


Fig.  99. — Sebaceous  Cyst  of  the  Back  of  the  Neck, 
Infected.  (New  York  Hospital,  service  of  Dr.  F.  W. 
Murray.) 


DIAGNOSIS    Or    THE    DIFFERENT    KINDS    01    TUMORS 


265 


multiple.  There  is  another  variety  of  -ehaceous  cyst  which  occurs,  no1  in  tin- 
skin  Inn  in  the  subcutaneous  tissue;  they  probably  arise  from  misplaced  em- 
bryonic cells  of  the  epithelial  type;  they  are  regarded  by  some  authoritii 
true  tumors.  Sebaceous  cysts  sometimes  become  converted  into  epithelioma. 
From  the  base  of  an  inflamed  sebaceous  cysi  there  occasionally  arises  a  cutane- 
ous horn.  Retention  cysts  occur  nol  infrequently  in  the  liver,  in  the  kidney, 
in  the  Fallopian  tube,  in  the  salivary  glands,  in  the  tear  sac,  and  in  the  gall 
bladder. 

.'!.  Retention  Cysts. — One  of  the  commonesl  forms  of  retention  cysts  is 
known  as  ranula;  if  forms  beneath  the  tongue,  on  the  floor  of  the  mouth,  a 
rounded,  translucent  tumor,  of  the  size  of  the  end  of  one's  thumb  or  larger, 
and  is  filled  with  mucus.  It  arises  from  the  closure  of  the  ducts  of  the 
submaxillary,  sublingual  glands,  and  of  the  ducts  of  the  Blandin-Nuhn 
glands. 

Implantation  Cysts. —  Implantation  cysts  originate  from  trauma,  usually 
from  punctured  wounds,  whereby  a  portion  of  the  epithelial  elements  of  the 
skin  is  displaced  from  its  normal  connections  and  implanted  in  a  new  situation 
where  the  cells  proliferate  and  cause  the  formation  of  a  cyst.  Such  cysts  have 
heen  noted  upon  the  palmar  surface  of  a  finger,  upon  the  scalp.,  in  the  iris,  and 
in  the  cornea. 

Cysts  Due  to  Congenital  Defects. — Certain  cysts  arise  when  tubular  struc- 
tures, normal  in  the  fetus,  fail  to  close;  they  are  known  as  tubular  cysts.     One 


Fig.  100. — Cysttc  Tumor  of  the  Palmar  Surface  ok  the  Middle  Fixnrn,  Following  an  Injvry. 
Probably  an  implantation  cyst.     (Author's  ci 


of  the  common  examples  is  cyst  of  the  urachus,  between  the  urinary  Madder  and 
the  umbilicus.  The  opening  may  remain  patent  into  the  bladder  or  through 
the  umbilicus,  or  both.  Cysts  also  arise  from  the  vitello  intestinal  duct,  the 
parovarian  tubules,  and  Gartner's  duct.     (See  Diseases  of  the  Abdomen.) 


266  TUMORS 

Dermoid  Cysts. — Dermoid  cysts  are  tumors  containing  more  or  less  perfectly 
formed  structures,  such  as  normally  are  only  developed  from  the  skin  or  mu- 
cous membrane,  and  found  in  localities  where  such  structures  do  not  properly 
exist.  They  were  divided  by  J.  Bland  Sutton  into  four  groups,  namely,  seques- 
tration dermoids,  tubulo  dermoids,  ovarian  dermoids,  and  dermoid  patches 
(moles). 

Sequestration  Dermoids. — Sequestration  dermoids  occur  in  those  places 
where  two  skin  surfaces  have  been  fused  together  in  the  embryo,  and  develop 
from  portions  of  epithelial  embryonic  tissue,  pinched  off,  as  it  were,  in  the 
process.  They  occur  in  the  middle  line  of  the  trunk,  posteriorly,  from  the 
occiput,  down  the  spine  to  the  perineum,  in  the  penis  and  scrotum,  and  up 
the  middle  line  of  the  front  of  the  body  to  the  neck.  In  the  face  and  neck 
they  occur  along  the  lines  of  the  branchial  fissures  and  the  fissures  of  the  face. 
In  the  face,  faults  of  development  may  occur,  according  to  Sutton,  in  three 
ways :  a  fissure  persists ;  a  fissure  may  close  imperfectly  and  leave  a  fistula ; 
a  portion  of  surface  epithelium  becomes  sequestrated  and  forms  a  dermoid. 
These  dermoids  occur  at  the  root  of  the  nose,  upon  the  scalp,  frequently  in 
the  neighborhood  of  the  orbit,  more  often  at  the  outer  than  at  the  inner  angle. 
They  seldom  attain  a  large  size.  They  consist  of  a  fibrous  sac  lined  with 
epithelial  structures  resembling  those  from  which  they  have  developed.  They 
contain  oily  material,  cholesterin,  hair,  epithelial  cells,  sebaceous  glands.  Der- 
moids in  general  may  contain,  in  addition  to  the  structures  mentioned,  teeth, 
cartilage,  bone,  and,  in  rare  cases,  brain,  nerve,  and  muscle  tissue,  and  some- 
times rudimentary  extremities.  Occasionally  the  contents  of  a  dermoid  con- 
sists merely  of  oily  material.  Dermoids  have  been  reported  containing  an  eye, 
and  in  one  case  a  mammary  gland.  The  hair  is  usually  fine  and  light  brown 
in  color;  it  may  be  short  and  curly,  or  cases  have  been  reported  in  which 
a  thick  switch  of  hair  existed,  in  one  case  five  and  one  half  feet  in  length 
(Munde). 

Tubulo  Dermoids. — Tubulo  dermoids  occur  in  embryonic  canals,  which 
normally  disappear  before  birth ;  of  these,  the  branchial  clefts,  the  thyro-glossal 
duct,  and  the  postanal  gut  sometimes  become  the  seat  of  dermoids.  For  the 
diagnosis  of  these  conditions,  see  Regional  Surgery. 

Ovarian  Dermoids. — All  the  structures  already  enumerated  may  occur 
in  ovarian  dermoids.  They  are  rather  important  tumors  because  they  may 
reach  a  large  size,  and  sometimes  become  infected  with  pyogenic  organisms, 
and  thus  threaten  the  life  of  the  patient.  They  possess  the  physical  peculiarity, 
on  account  of  the  puttylike  nature  of  their  contents,  that  if  indented  by  the 
examining  fingers  the  indentation  may  remain  for  some  time.  If  they  contain 
a  large  amount  of  hair,  a  crepitation  may  be  felt  when  examining  the  tumor 
(Kocher). 

Dermoid  Patches — Moles. — Moles  are  congenital  pigmented  patches 
upon  the  skin,  and  are  often  hairy.  They  may  be  very  small,  or  may  involve 
a  considerable  portion  of  the  cutaneous  surface.     They  frequently  occur  upon 


DIAGNOSIS   OF   THE    DIFFERENT    KINDS    OF   TUMORS 


267 


the  face.  Clinically  they  are  importanl  because  they  nol  infrequently  become 
the  Btarting  poinl  of  ;i  sarcoma,  sometimes  of  the  melanotic  i \  j •« -. 

Cholesteatoma. — Cholesteatoma  are  cysts,  sometimes  dermoid,  sometimes 
atheromatous  cysts,  the  contents  of  which  are  made  up  of  fat  and  of  crystalline 
plaques  of  cholesterin.  The  name  "mother-of-pearl"  tumor  i.~  sometimes  used 
mi  accounl  of  the  white,  glistening  appearance  of  the  cholesterin  crystals. 
They  occur  in  the  membranes  of  the  brain,  sometimes  in  the  ventricles,  in  the 
middle  ear,  the  mastoid  process,  and  the  petrous  portion  <»f  the  temporal  bone, 
and  in  some  of  the  glandular  organs,  notably  in  the  ovary.  They  are  regarded 
h\  some  observers  as  belonging  to  the  endotheliomata.  They  are  benign  tu- 
mors, hut  may  give  rise  to  dangerous,  and  even  fatal  symptoms — in  the  ear 
by  becoming  infected  and  in  the  meninges  of  the  brain  by  pressure. 

Psammoraata. —  These  tumors  occur  in  the  interior  of  the  skull  and  in  the 
spinal  canal:  they  are  connected  with  the  pia  mater  of  the  brain,  and  some- 
times they  grow  from  the  choroid  plexuses  of  the  ventricles.  They  are  sup- 
posed to  be  related  to  the  endotheliomata.  They  consist  of  spherical  masses 
of  endothelium  or  epithelium,  surrounded  by  connective  tissue.  They  often 
undergo  calcification.  They  lead,  if  they  grow  to  considerable  size,  to  pressure 
symptoms  of  a  cerebral  or  spinal  character,  according  to  their  situation  to  head- 
ache, and  to  irritations  and  palsies  of  the  optic,  facial,  trigeminal,  and  auditory 
nerves.  When  they  affect  the  motor  paths  of  the  brain  or  spinal  cord  they 
lead  to  progressive  paraple- 
gias, ataxia,  and  other  symp- 
toms, ending  finally  in  death. 

Hydroceles.  —  These  are 
cystlike  tumors  containing 
serum.  They  occur  when  a 
pouch  of  peritoneum,  cither 
normal  or  due  to  a  hernial 
protrusion  of  the  peritoneal 
sac,  becomes  the  seat  of  a  low 
grade  of  inflammation  or  ir- 
ritation. Such  are  hydrocele 
of  the  tunica  vaginalis  testis, 
of  the  canal  of  Xuck.  Also 
the  serous  effusions  into  her- 
nial sacs,  rarely  similar  effu- 
sions between  the  layers  of  the 
great  omentum. 

Diverticula.  —  These  are 
dilatation     sacs    occurring    as 

hernial  protrusions  from  mucous  canals.  They  occur  raosl  often  in  connection 
with  the  alimentary  canal,  from  the  pharynx,  the  esophagus,  or  the  intestine, 
sometimes  from  the  urinary  bladder.     Similar  protrusions  occur  congenitally 


Fig.  101. — Cystic  Dilatation  of  Both  Phi  -path  lab 
Burs.i:.      (NYw  York  Hospital,   author's  c 


268 


TUMORS 


from  the  canal  of  the  central  nervous  system.     These  latter  are  known  as  neural 
cysts.   Among  them  may  be  mentioned  meningocele,  cephalocele,  hydrencephalo- 

cele,  spina  bifida.  A  discussion 
of  the  diagnosis  of  these  condi- 
tions will  be  found  in  the  chap- 
ters on  Regional  Surgery. 

Bursae. — Over  certain  bony 
prominences,  and  where  mus- 
cles and  tendons  pass  over  bony 
points,  there  exist  normally,  or 
are  developed  as  the  result  of 
intermittent  but  chronic  me- 
chanical pressure  and  irrita- 
tion, thin-walled,  fibrous  sacs 
containing  clear  fluid  resem- 
bling normal  synovia.  They 
sometimes  cause  pain  and  in- 
convenience by  becoming  in- 
flamed. Such  bursa  are  de- 
veloped over  the  patella  (the 
condition  is  known  as  "  house- 
maid's knee"),  sometimes  be- 
neath the  patellar  tendon  (the 
ligamentum  patellre),  over  the 
tuberosity  of  the  ischium,  over 
the  great  trochanter,  over  the 
olecranon  process  of  the  ulna, 
over  the  metatarso-phalangeal 
joint  of  the  great  toe,  associ- 
ated with  bunion  (hallux  val- 
gus), over  the  outer  end  of  the 
clavicle.  These  conditions  are 
most  often  clue  to  occupation 
or  to  habit,  such  that  the  bursa 
develops  over  points  exposed  frequently  to  mechanical  pressure.  Further  de- 
tails will  be  found  under  the  head  of  Regional  Surgery. 

Parasitic  Cysts. — Eciiinococcus  (Hydatid  Cyst). — The  variety  of  tape- 
worm known  as  Taenia  eciiinococcus  inhabits  the  intestine  of  dogs,  wolves, 
jackals,  and  allied  forms.  It  is  a  four-jointed  worm,  less  than  a  quarter  of 
an  inch  in  length.  The  first  joint  is  the  head.  It  contains  upon  the  terminal 
prominence,  known  as  the  rostellum,  four  suckers  and  numerous  booklets.  The 
fourth,  or  terminal,  joint  contains  the  male  and  female  sexual  apparatus,  com- 
bined  in  the  one  individual.  The  ova  contained  in  the  excreta  of  the  affected 
animal,  and  swallowed  by  man  through  contaminated  water  or  food,  are  taken 


Fig.  102. —  Cystic  Dilatation  of  Both  Prepatellar 
Btjrs/e  and  of  Both  Olecranon  Bursae.  (New  York 
Hospital,  service  of  Dr.  Bolton.) 


DIAGNOSIS    OF   THE   DIFFERENT   KINDS   OF   TUMORS  269 

up  bv  the  lymph  and  blood-vessels  of  the  intestine,  and  are  carried  by  the 
portal  circulation  to  the  liver,  where  they  lodge  and  frequently  develop.  Echi- 
nococcus  is  a  rare  disease  in  America.  It  occurs  with  the  greatest  frequency 
in  those  countries  where  the  people  live  in  close  contact  with  numerous  dogs — 
notably  in  Iceland,  and  in  sheep-raising  countries  like  Australia ;  on  the  Con- 
tinent of  Europe  it  is  not  a  very  common  disease. 

The  liver  is  the  most  frequent  seat  of  the  disease ;  the  lung,  the  kidneys, 
the  spleen,  the  brain,  the  bones  may,  however,  be  the  seat  of  the  infection. 
Wherever  the  embryos  lodge  they  set  up  an  irritation  of  the  tissues,  and  a 
fibrous  envelope  forms  about  the  embryo;  within  this  envelope  the  cyst  de- 
velops. It  is  described  as  having  two  walls — an  external  one  formed  of  elastic 
tissue  and  quite  vascular,  and  an  internal  one,  known  as  the  endocyst,  or 
parenchymatous  layer,  from  the  surface  of  which  the  so-called  brood  capsules 
develop,  and  in  these  the  little  echinococcus  heads  or  scolices  are  formed. 
These  have  a  so-called  rostellum,  armed  with  a  double  row  of  hooklets  and 
four  suckers.  The  capsule  enlarges,  forming  a  cyst.  The  cyst  may  remain 
single,  or  new  cysts  may  develop,  either  within  or  without  the  wall  of  the 
parent  cyst ;  and  again,  from  the  wall  of  these  so-called  "  daughter  cysts  " 
other  cysts  may  form.  The  tumors  thus  produced  in  the  liver  are  often  of 
considerable  size ;  for  example,  they  may  hold  several  quarts  of  fluid.  The  cysts 
contain  usually  a  clear,  light,  straw-colored,  watery  fluid,  of  a  specific  gravity 
of  1.005,  and  alkaline  in  reaction.  Albumen  is  usually  absent,  unless,  as  is 
sometimes  the  case,  hemorrhage  has  taken  place  into  the  cavity ;  sodium  chlorid 
is  present  in  considerable  quantity.  In  echinococcus  of  the  liver  the  cysts  are 
said  to  contain  leucin  and  tyrosin,  and  those  in  the  kidney  uric  and  oxalic 
acids.  The  recognition  of  the  hooklets  establishes  the  diagnosis.  The  entire 
scolex  is  about  one  fiftieth  of  an  inch  in  length,  and  the  hooklets  are  seen 
under  the  microscope,  singly  or  in  groups,  in  the  fluid  withdrawn  from  the  sac. 

Manv  of  these  cvsts  attain  no  o-reat  size ;  their  inhabitants  die,  the  fluid 
contents  of  the  cyst  are  absorbed,  and  the  remains  undergo  fatty  or  calcareous 
degeneration.  In  another  form  of  the  disease  innumerable  minute  cysts,  none 
of  them  larger  than  a  pea,  are  scattered  throughout  the  liver  (echinococcus 
multilocularis).  If  the  cysts  grow  to  considerable  size,  they  may  finally  rup- 
ture into  one  of  the  body  cavities — if  into  the  peritoneum,  they  may  set  up 
serious  or  fatal  peritonitis ;  if  into  the  alimentary  canal,  the  hooklets,  or  even 
cysts,  may  be  passed  per  rectum ;  if  into  the  pelvis  of  the  kidney  or  the  urinary 
bladder,  the  characteristic  structures  may  be  found  in  the  urine ;  if  into  the 
bronchi,  they  will  be  found  in  the  sputum.  In  the  abdomen  the  cysts  form 
a  rounded,  tense,  smooth,  elastic  tumor.  If  one  hand  is  placed  upon  the  cyst 
while  the  cyst  wall  is  percussed  upon  the  opposite  side,  a  peculiar  vibratory 
thrill  is  sometimes  felt. 

Echinococcus  Cyst  of  Bone. — The  disease  is  usually  of  the  multilocular 
variety.  Out  of  fifty-two  cases  quoted  by  Tillmanns,  eleven  were  in  the  hu- 
merus, eight  in  the  tibia,  six  in  the  femur,  one  in  a  phalanx,  eleven  in  the 


270  TUMORS 

pelvis,  and  four  each  in  the  skull,  scapula,  and  sternum ;  one  in  a  rib.  The 
tumors  are  of  slow  growth,  and  may  exist  for  years  without  giving  rise  to 
marked  symptoms.  They  may  finally  become  painful,  the  bone  may  become 
enlarged,  and  the  picture  presented  is  that  of  a  central  tumor  of  bone  which 
has  broken  through,  or  is  about  to  break  through,  into  the  soft  parts.  The 
diagnosis  may  be  made  *by  the  aspirating  needle  in  some  cases.  They  some- 
times cause  suppuration  and  the  production  of  sinuses.  The  discharged  pus 
contains  much  cholesterin ;  there  is  little  or  no  production  of  new  bone,  as  is 
the  case  with  ordinary  osteomyelitis,  followed  by  necrosis.  As  already  stated, 
the  cysts  are  minute,  the  formation  of  large  cysts  in  bone  being  rare.  Spon- 
taneous fracture  sometimes  occurs.  For  echinococcus  of  other  localizations, 
see  Regional  Surgery. 

Cysticercus  Cellulose. — During  one  of  the  stages  of  its  existence  the 
Taenia  solium,  one  of  the  varieties  of  tapeworm,  inhabits,  not  infrequently, 
the  muscular  tissues  of  the  pig.  An  animal  butchered  in  this  condition  is 
known  as  "  measly  pork."  If  such  flesh  is  eaten  by  human  beings  in  a  raw 
or  imperfectly  cooked  state,  the  protective  covering  may  be  digested,  and  the 
worm  find  its  way  through  the  wall  of  the  alimentary  canal  and  by  the  blood 
current  to  various  situations  in  the  body — the  subcutaneous  tissues,  the  mus- 
cles, the  brain,  the  abdominal  organs,  the  eye,  and  other  situations.  When 
they  lodge  in  the  brain,  the  eye,  or  other  important  organs,  they  give  rise  to 
more  or  less  marked  symptoms  of  their  presence — epilepsy,  interference  with 
vision,  etc.  When  situated  in  the  subcutaneous  tissues  or  in  muscle,  they  pro- 
duce no  symptoms  save  that  of  their  mechanical  presence  as  round  or  ovoid, 
hard  or  elastic,  little  tumors,  varying  in  size  from  that  of  a  small  bean  to  that 
of  a  hazel  nut.  They  are  painless  and  insensitive,  do  not  increase  in  size,  and, 
unless  they  become  infected  and  suppurate,  produce  no  symptoms  whatever. 
The  cysts  may  be  few  in  number  or  very  numerous. 

They  are  to  be  differentiated  from  Fibroma  molluscum  from  the  fact  that 
the  latter  is  situated  in  or  upon  the  skin;  that  the  skin  covering  a  fibroma  is 
frequently  flabby  and  thin ;  further,  that  the  fibromata  are  often  pedunculated. 
The  orifices  of  sebaceous  glands  are  often  seen  upon  the  surface  of  a  fibroma. 
Lipomata  and  sebaceous  cysts  are  notably  softer  tumors.  The  neuro-fibromata 
are  situated  along  the  course  of  nerve  trunks,  and  are  usually  painful.  They 
are  to  be  differentiated  from  sarcomata  from  the  fact  that  they  remain  quies- 
cent and  do  not  grow,  and  that  they  are  movable  beneath  the  skin.  From 
subcutaneous  gummata  they  are  to  be  distinguished  from  the  fact  that  the 
latter  become  adherent  to  the  skin,  and  finally  break  down,  showing  the  char- 
acteristic signs  of  late  syphilitic  ulceration. 

When  they  occur  upon  the  conjunctiva  they  form  small  cystic  tumors  be- 
tween the  conjunctiva  and  the  sclera.  They  are  usually  firm,  often  movable; 
they  may  have  a  fibrous  cyst  wall,  or,  on  the  other  hand,  the  sac  may  be  so 
thin  and  translucent  that  the  head  of  the  worm  can  be  seen  as  a  minute  white 
dot.     The  diagnosis  is  made  certain  by  finding  the  hooklets  in  the  extirpated 


DIAGNOSIS    OF   THE    DIFFERENT   KINDS    OF    TUMORS  271 

sac.  When  they  are  situated  beneath  the  retina  they  cause  separation  of  this 
membrane  and  disturbances  of  vision.  If  the  media  of  the  eye  remain  clear, 
they  can  be  sometimes  recognized  with  the  ophthalmoscope  as  little  bluish  cysts 
in  the  fundus  of  the  eye.  The  head  of  the  worm  may  be  recognizable,  and 
the  parasite,  if  alive,  may  even  be  seen  to  move.  In  the  vitreous  humor  they 
set  up  an  irritation,  and  produce  cloudiness  of  that  medium.  If  the  head 
merely  projects  into  the  vitreous  humor,  it  may  here  also  be  recognized  through 
the  ophthalmoscope. 

Teratoma 

Under  this  name  are  included  a  variety  of  conditions  which  depend  upon 
malformations  occurring  in  the  embryo.  The  various  forms  of  double  monsters 
as  well  as  the  congenital  tumors  containing  heterogeneous  masses  of  any  and 
every  sort  of  tissue  are  all  included  in  this  class.  They  are  supposed  to  arise 
when  a  double  embryo  is  contained  in  a  single  ovum,  and  when  one  of  the 
embryos  goes  on  to  full  development  while  the  other  develops  incompletely  and 
remains  attached  to  the  former  as  a  parasite.  The  tumors  may,  as  stated, 
contain  every  variety  of  tissue.  From  the  surgical  standpoint  these  tumors 
are  chiefly  interesting  when  they  occur  in  such  form  and  in  such  situations 
that  they  can  be  removed.  Tumors  containing  a  variety  of  tissues  occurring 
in  the  ovary  and  testis  belong  to  the  teratomata.  They  usually  remain  quies- 
cent during  the  early  years  of  life,  and  do  not  take  on  an  active  growth  until 
the  period  of  puberty.  The  occurrence  of  teratomata  will  be  spoken  of  more 
particularly  in  the  chapters  on  Regional  Surgery. 


CHAPTER    VIII 

FRACTURES  AND   DISLOCATIONS 

FRACTURES 

The  diagnosis  of  fractures  is  to  be  made  partly  from  objective  signs  and 
partly  from  the  history  of  the  case  and  the  subjective  symptoms.  The  difficul- 
ties in  the  recognition  of  fractures  vary  greatly;  in  many  instances  the  pres- 
ence of  a  fracture  can  be  recognized  at  a  glance ;  in  others,  ordinary  methods 
of  examination  may  entirely  fail  to  enable  the  surgeon  to  say  whether  a  frac- 
ture exists  or  not. 

Causation  of  Fractures 

Before  speaking  of  the  diagnosis  of  fractures  in  general,  it  is  necessary  to 
refer  briefly  to  the  causes  of  fracture,  and  to  mention  some  of  the  varieties  of 
fracture. 

Predisposing  Causes. — Many  more  fractures  occur  in  men  than  in  women, 
owing  to  the  fact  that  men  are  more  liable  to  accidental  violence  from  their 
mode  of  life  and  occupations.  In  young  children  fractures  are  rare.  Certain 
bones,  from  their  shape  and  position,  are  more  liable  to  fracture  than  others 
— the  clavicle  from  its  curved  shape,  the  phalanges  of  the  fingers  from  their 
exposed  position.  In  old  age  a  predisposing  cause  exists  in  the  rarefying 
change  in  the  bones  incident  to  senility,  and  fractures  are  relatively  more 
common  in  old  people. 

Active  or  Determining  Causes. — Active  or  determining  causes  of  fracture 
are  external  violence — direct  or  indirect — and  muscular  violence.  There 
exists,  also,  a  class  of  fractures  due  to  local  disease  of  the  bone  itself  or  to 
general  causes,  such  that  fractures  occur  from  degrees  of  violence  insuffi- 
cient to  produce  them  in  healthy  subjects;  these  are  known  as  spontaneous 
fractures,  sometimes  as  pathological  fractures. 

Fractures  Due  to  External  Violence — Direct  or  Indirect. — A  frac- 
ture is  said  to  be  due  to  direct  violence  when  the  bone  is  broken  at  the  point 
of  application  of  the  force  to  its  surface;  to  indirect  violence  when  the  frac- 
ture occurs  at  some  other  point  than  that  to  which  the  force  was  applied.  A 
very  important  practical  difference  exists  between  these  two  classes. 

Fractures  by  Direct  Violence. — Such  fractures  are  often  accompanied  by 
a  wound  or  contusion  of  the  soft  parts;  such  a  wound  may  communicate 
272 


FRACTURES  273 

directly  with  the  point  of  fracture,  or  the  contused  tissues  may  subsequently 
slough  and  expose  the  fractured  bone.  Such  an  injury  may  be  slight  or  of 
any  degree  of  gravity  up  to  the  crushing  of  all  the  tissues  of  the  limb.  Frac- 
tures by  direct  violence  occur  most  often  when  some  portion  of  the  body 
being  at  rest  is  struck  by  a  moving  object — a  club,  a  stone,  a  bullet,  the 
wheel  of  a  wagon  or  locomotive,  or  a  moving  piece  of  machinery;  less  often 
by  falls  from  a  height  upon  a  flat  surface  (unless  the  individual  strikes  some 
intervening  object  before  reaching  the  ground,  or  falls  upon  his  head).  If 
he  falls  upon  his  feet  or  hands  indirect  fractures  usually  result — although  in 
such  falls  upon  the  feet  direct  crushing  fracture  of  the  os  calcis  is  not  uncommon. 

Fractures  by  Indirect  Violence. — These  fractures  occur  very  often  as  the 
result  of  falls  either  from  a  height  or  a  simple  fall,  as  from  slipping  upon  ice, 
a  misstep,  etc.  The  majority  of  fractures  of  the  long  bones  occur  in  this 
way.  The  force  may  act  in  such  a  manner  that  the  bone  against  which  the 
force  is  applied  is  broken,  or  through  the  medium  of  other  bones  the  fracture 
occurs  in  a  distant  bone.  The  bone  may  be  (1)  crushed;  (2)  bent;  (3)  twisted; 
(4)  torn  apart.  Examples:  1.  Impacted  fracture  of  the  neck  of  the  femur  from 
a  fall  upon  the  great  trochanter.  2.  Many  fractures  of  the  long  bones.  3.  Frac- 
ture of  the  bones  of  the  leg  when,  the  foot  being  firmly  held,  the  whole  body  is 
rotated.     4.  Fracture  of  the  internal  malleolus  from  abduction  of  the  foot. 

Muscular-action  Fractures.- — Fractures  from  violent  contraction  of  the 
muscles  occur  most  often  in  the  patella,  the  olecranon,  occasionally  in  the 
humerus.  Much  more  rarely  the  femur,  the  bones  of  the  forearm,  the  leg, 
the  ribs,  acromion,  and  other  bones. 

Spontaneous  and  Pathological  Fkactures. — As  the  result  of  hemi- 
plegias, locomotor  ataxia,  pregnancy,  osteomalacia,  and  prolonged  disuse  of 
the  limbs  from  disease  of  the  joints;  the  bones  may  undergo  a  rarefying  oste- 
itis similar  to,  and  often  in  excess  of,  that  which  accompanies  old  age;  under 
such  conditions  fractures  may  occur  from  degrees  of  violence  entirely  in- 
adequate to  produce  them  in  healthy  persons.  For  example:  The  femur 
may  break  by  turning  over  in  bed ;  or  the  humerus  while  raising  the  hand 
suddenly  to  the  head ;  or  a  fracture  of  the  tibia  by  a  misstep  in  going  down- 
stairs or  from  a  slight  blow.     These  fractures  sometimes  unite  promptly. 

Rachitis. — In  children  who  have  rachitis  the  bones  are  sometimes  broken 
from  slight  degrees  of  violence.  Union  may  be  delayed.  Sarcoma  and  car- 
cinoma, primary  in  the  bones,  or  due  to  secondary  deposits,  is  not  infrequent, 
and  destroys  and  causes  absorption  of  bony  tissue,  and  may  lead  to  fracture 
from  slight  causes.  While  localization  may  take  place  in  any  bone,  the  femur 
is  most  often  affected,  the  humerus  next.  ~No  symptoms  may  precede  the 
fracture,  or  the  bone  may  have  been  the  seat  of  considerable  pain.  Strangely 
enough,  the  fractures  unite  in  a  small  proportion  of  cases. 

Osteomyelitis. — In  those  cases  of  suppurative  inflammation  of  the  bones 

attended  by  necrosis  there  is  usually  so  large  a  reproduction  of  new  bone 

during  the  separation  of  the  sequestrum  that  fractures  are  not  at  all  likely 
19 


274  FKACTUKES    AND   DISLOCATIONS 

to  occur  except  as  the  result  of  the  weakening  of  the  bone  by  extensive  oper- 
ations for  the  removal  of  the  sequestrum,  or  the  proper  drainage  of  purulent 
collections  in  its  neighborhood.  Under  such  circumstances  fractures  may 
be  produced,  either  during  the  operation  or  soon  after,  during  movements 
of  the  limb.  Such  fractures  always  heal  readily,  and  need  give  the  surgeon 
no  serious  anxiety. 

Ecliinococcus. — The  occurrence  of  spontaneous  fracture  as  the  result  of 
bone  destruction  produced  by  hydatids  of  the  diaphases  of  the  long  bones  has 
already  been  mentioned. 

Syphilis. — Circumscribed  or  diffuse  gummatous  infiltration  of  the  shafts 
of  the  long  bones  with  absorption  or  destruction  of  bone  substance  may  lead 
to  the  occurrence  of  fracture  from  very  slight  degrees  of  violence.  Such  frac- 
tures may  be  attended  by  very  little  pain.  The  distinctive  signs  of  fracture 
are  present.  Under  fixation  and  the  use  of  mercury  and  iodid  of  potash  the 
fractures  commonly  unite  readily.     Delayed  union  is  sometimes  observed. 

Intra-uterine  and  Intrapartum  Fractures. — Blows  upon  or  wounds  of 
the  abdomen  of  the  mother  may  produce  fractures  of  the  bones  of  the  fetus. 
Such  cases  are  rare,  and  it  is  not  possible  always  at  the  time  of  birth  to  deter- 
mine whether  the  fracture  was  produced  in  utero  or  during  delivery,  nor  even 
to  state  positively  whether  a  fracture  exists  or  merely  a  deformity  due  to 
imperfect  ossification,  except  by  means  of  a  skiagraph.  Fractures  during  labor 
are  most  often  caused  by  instruments  used  to  deliver  the  fetus,  or  by  the 
manipulations  made  during  version,  more  rarely  by  pressure  against  the  par- 
turient canal.     They  possess  no  special  diagnostic  interest. 

The  Varieties  of  Fracture 

Fractures  may  be  classified  in  various  ways  according  to  the  relation  of 
the  broken  bone  to  injuries  of  the  soft  parts.  We  speak  of  fractures  as  com- 
pound or  simple.  A  compound  fracture  is  one  in  which  a  wound  of  the  soft 
parts  exists,  such  that  the  fracture  is  in  communication  with  the  external  air. 
A  simple  fracture  is  one  in  which  no  such  communication  exists.  Fractures 
may  be  further  classified,  according  to  the  extent  of  the  injury  of  the  bone, 
into  incomplete  or  complete :  "  1.  The  incomplete  fractures  may  be  divided  into 
(a)  fissures;  (b)  "green-stick"  fractures,  bent  bones;  (c)  depressions;  (d) 
separation  of  a  splinter  or  of  an  apophysis.  2.  Complete  fractures  subdivided, 
according  to  (a)  direction  and  character  of  the  line  of  the  fracture,  into  trans- 
verse, oblique,  longitudinal,  spiral,  toothed  or  dentate,  V-,  Y-,  or  T-shaped, 
and  comminuted;  (&)  seat  of  the  fracture  into  fracture  of  the  shaft,  of  the 
neck,  of  the  upper,  middle,  or  lower  third,  intercondyloid,  separation  of  epiph- 
ysis ;  and,  (c)  if  extending  into  a  joint,  intra-articular.  3.  Multiple  fractures, 
comprising  fractures  of  two  or  more  nonadjacent  bones  and  two  or  more  frac- 
tures of  the  same  bone.     4.  Gunshot  fractures."     (Stimson's  classification.)1 

»"A  Practical  Treatise  on  Fractures  and  Dislocations,"  Lewis  A.  Stimson.  Page  22.  Lea 
Bros.     1900. 


FRACTURES  275 

Incomplete  Fractures. —  Fissures. —  Fissured  fractures  arc  characterized  by 
a  crack  or  fissure  in  the  bone,  but  which  does  no1  extend  in  such  a  manner 
as  to  produce  a  separate  fragment.  It  is  frequently  seen  in  the  bones  forming 
the  vault  of  the  skull,  and  is  exceedingly  common  in  the  shafts  of  the  long 
bones  as  the  result  of  wounds  made  by  steel-covered  rifle  bullets  of  small 
caliber.  It  cannot  be  diagnosticated  except  in  compound  fractures,  and  in 
these  its  importance  depends  upon  the  fact  that  if  a  fissure  extends  into  a 
neighboring  joint,  it  may  form  an  avenue  of  infection  from  the  fracture  into 
the  joint. 

Green-stick  Fracture — Bent  Bone. — In  nearly  all  cases  this  is  a  true 
fracture,  which  does  not,  however,  involve  the  entire  thickness  of  the  bone. 
The  bone  is  bent,  splintering  occurs  upon  the  convex  side  of  the  bend,  and 
compression  of  the  bone  upon  the  concave  side.  This  form  of  fracture  oc- 
curs in  the  long  bones  of  children ;  most  often  in  the  bones  of  the  forearm, 
less  frequently  in  the  clavicle,  and  rarely  in  other  situations.  It  does  not 
occur  in  the  short  bones.  Angular  deformity  exists  as  the  result  of  this 
fracture. 

Depressions. — Depressions  are  indentations  of  the  surface  of  flat  or  spongy 
bones  produced  usually  by  direct  violence. 

Separation  of  a  Splinter,  or  an  Apophysis. — As  the  result  of  direct 
violence  a  fragment  may  be  cut  or  broken  from  the  surface  of  a  bone.  Such 
injuries  are  commonly  the  result  of  saber  cuts  and  the  like.  The  spongy  por- 
tions of  the  long  bones,  the  external  table  of  the  skull,  are  common  sites.  I 
saw  such  an  injury  (a  simple  fracture)  produced  in  the  following  manner: 
A  man  was  struck  bv  an  automobile  on  the  outer  surface  of  his  rielit  thiffh, 
his  legs  were  knocked  from  under  him,  and  his  body  described  a  somersault 
so  that,  as  he  fell,  his  left  shoulder  struck  against  the  edge  of  the  metal  hood 
covering  the  engine.  A  small  fragment  was  chipped  off  the  posterior  border 
of  the  outer  third  of  the  left  clavicle.  The  fracture  was  simple  and  the 
continuity  of  the  shaft  was  not  destroyed. 

The  Separation  of  an  Apophysis. — This  occurs  from  violent  muscular 
action,  or  by  violent  traction  upon  a  ligament,  so  that  a  portion  of  bone  is  torn 
away  from  its  attachment  to  the  main  portion  of  the  bone.  Such  a  fragment 
may  be  small  or  of  considerable  size.  Examples  are  fracture  of  the  coracoid 
process  of  the  scapula,  fracture  of  the  olecranon,  fracture  of  the  coronoid  process 
of  the  ulna  in  backward  dislocation  of  the  elbow  by  muscular  action,  fracture  of 
the  internal  malleolus  by  abduction  of  the  foot  in  Pott's  fracture,  and  fracture 
of  the  external  border  of  the  lower  end  of  the  tibia,  also  a  frequent  accompani- 
ment of  the  same  injury. 

Complete  Fractures. — Complete  fractures  are  those  in  which  a  bone  is  broken 
into  two  or  more  separate  fragments.  It  is  customary  to  classify  these,  ac- 
cording to  the  direction  of  the  line  of  fracture,  into  transverse,  oblique, 
longitudinal,  spiral,  toothed  or  dentate  V-,  Y-,  or  T-shaped,  splintered.  In 
order  to  economize  space  the  details  in  regard  to  the  diagnosis  of  the  various 


276  FRACTURES    AND    DISLOCATIONS 

types  of  fracture  of  the  long'  bones  will  be  dwelt  upon  more  particularly  under 
Regional  Surgery.  The  commonest  varieties  are  the  transverse  and  oblique 
fractures,  as  the  result  of  such  violence  as  tends  to  bend  the  bone.  If  the 
broken  surfaces  of  both  fragments  are  markedly  jagged,  the  fracture  is  toothed 
or  dentate.  Certain  varieties — the  V-shaped  fracture,  for  example- — occur  most 
often  in  the  tibia.  The  Y-  and  T-shaped,  at  the  lower  end  of  the  humerus  and 
femur,  and  involve  the  elbow-  and  knee-joint  respectively.  A  comminuted  frac- 
ture is  one  in  which  the  bone  is  broken  into  several  fragments.  Spiral  fractures 
are  produced  by  twisting  strains ;  the  line  of  fracture  pursues  a  spiral  course 
along  the  shaft.  Longitudinal  fractures  are  those  in  which  the  line  of  frac- 
ture crosses  the  bone,  either  on  a  very  long  slant  or  is  approximately  parallel 
to  the  long  axis  of  the  bone.     They  are  comparatively  rare. 

The  use  of  the  X-rays  have  enabled  us  to  study  fractures  in  a  manner 
formerly  quite  impossible  in  the  living  subject.  We  are  able  in  most  cases  to 
determine  the  direction  of  the  lines  of  fracture,  the  number  of  fragments,  the 
character  of  the  displacements,  the  obstacles  to  reduction,  and  further  to  tell 
with  certainty  whether  our  efforts  at  reduction  have  been  successful  and  whether 
our  dressings  are  efficient. 

Separation  of  Epiphyses. — The  epiphyses  unite  at  different  ages  in 
different  bones.  In  men,  union  of  all  the  epiphyses  is  complete  by  the  end  of 
the  twenty-fifth  year ;  in  women,  at  the  age  of  twenty-two.  In  the  young,  such 
separations  occur  at  the  upper  and  lower  end  of  the  humerus,  at  the  lower 
end  of  the  radius,  at  the  lower  end  of  the  femur,  more  rarely  in  other  situations. 
The  diagnosis  is  usually  easily  made  from  the  physical  signs.  It  can  be  made 
with  great  ease  by  means  of  an  X-ray  picture.  For  the  diagnosis  of  separation 
of  the  epiphyses  and  fractures  involving  joints,  see  Regional  Surgery. 

Multiple  Fractures. — By  this  term  is  meant  either  that  two  or  more  bones 
are  fractured,  or  that  two  or  more  distinct  and  separate  fractures  are  present 
in  the  same  bone. 

Compound  Fractures. — The  existence  of  an  external  opening  in  the  soft  parts 
communicating  with  the  seat  of  a  fracture  adds  greatly  to  the  gravity  of  the 
injury,  unless  pyogenic  infection  is  avoided.  Compound  fractures  are  pro- 
duced usually  by  direct  violence.  The  force  which  causes  the  wound  of  the 
soft  parts  also  fractures  the  bone.  A  certain  smaller  proportion  occur  from 
indirect  violence  by  a  continuance  of  the  force  pushing  the  broken  end  of  a 
bone  through  the  soft  parts,  thus  creating  a  wound  of  the  skin  from  within 
outward.  In  some  cases  the  fracture,  at  first  simple,  is  rendered  compound  by 
penetration  of  the  skin  by  a  sharp  bony  fragment  as  the  result  of  injudicious 
handling,  of  efforts  on  the  part  of  the  patient  to  use  the  limb,  of  involuntary 
muscular  spasm,  of  imperfect  retentive  apparatus  during  the  struggles  of  an 
insane  or  delirious  patient.  Finally,  by  sloughing  of  the  contused  parts  over 
the  seat  of  fracture.  Compound  fractures  by  direct  violence  are  often,  from 
the  character  of  the  violence  causing  them,  among  the  gravest  injuries.  Such 
are  the  fractures  resulting  from  the  passage  of  a  heavy  vehicle  over  the  limbs — 


FRACTURES 


277 


a  locomotive,  a  trolley  car,  or  the  like.  Limbs  ground  up  in  the  toothed  wheels 
of  moving  machinery  or  caught  between  the  buffers  of  railway  cars  are  cases 
of  compound  fracture  of  such  gravity  that  the  mere  breaking  of  the  bone  is  a 
matter  of  minor  importance.  The  diagnosis  of  compound  fractures  is  usually 
easy,  as  far  as  determining  the  presence  of  fracture  is  concerned.  To  estimate 
the  gravity  of  the  associated  injuries  of  the  soft  parts  is  not  always  so  simple. 
It  is  well  to  bear  in  mind  that  the  size  of  the  opening  in  the  skin  bears  no 
necessary  relation  to  the  amount  of  destruction  to  the  subcutaneous  tissues, 
muscles,  blood-vessels,  etc.  It  often  happens  that  the  wound  of  the  skin  is 
small  while  the  injury  to  the  deeper  parts  is  extensive.  If  there  is  a  wound 
of  the  soft  parts  in  the  vicinity  of  a  fracture,  even  though  no  direct  communi- 
cation appears  to  exist  between  the  two,  the  case  should  be  regarded  as  a  case 
of  compound  fracture,  and  treated  accordingly.  A  large  proportion  of  com- 
pound fractures  are  attended  by  shock  of  a  grave  and  even  fatal  character, 
owing  to  associated  injuries. 

Gunshot  Fractures. — In  the  chapter  on  Gunshot  Wounds,  mention  has  been 
made  of  some  of  the  characters  of  gunshot  fractures.  The  reader  is  referred 
to  that  chapter  and  to  wounds  of  regions. 

The  Objective  Signs  of  Fracture 

The  objective  signs  of  fracture  are  deformity,  abnormal  mobility,  crepitus, 
ecchymosis,  swelling,  the  formation  of  blebs.  The  subjective  symptoms  of 
fracture  include  pain,  tenderness,  loss  of  function,  and  with  these  may  be 
included  the  history  of  the  injury,  as  related  by  the  patient.     The  deformity 


Fig.  103. 


-Deformity  in  Recent  Fracture  of  Radius  and  Ulna  in  the  Lower  Third  of  the 
Forearm.     (New  York  Hospital  collection.) 


278 


FRACTURES    AND    DISLOCATIONS 


following  fractures  varies  greatly.  In  many  instances  an  obvious  bend  or 
angular  deflection  of  a  limb  renders  itself  evident  to  the  most  casual  observer. 
In  other  instances  the  deformity  may  be  absent  or  slight,  or  it  may  occur  in 
such  situations  that  it  is  very  difficult  to  appreciate.  Swelling  of  the  soft  parts 
near  a  broken  bone  often  takes  place  very  soon  after  the  receipt  of  the  injury, 
due  to  effusion  of  blood  from  the  vessels  of  the  broken  bone,  periosteum,  and 
injured  soft  parts.  Such  swelling  may  obscure  the  displacement  of  the  broken 
bone,  or,  on  the  other  hand,  may  lead 
to  an  appearance  of  deformity  in  the 
bones  themselves  where  none  exists. 


Fig.  104. — Old,  very  Oblique  Fracture  of 
the  Shaft  of  the  Femur,  Marked  Long- 
itudinal Displacement,  Showing  Great 
Shortening  of  the  Limb.  The  attempt  to 
overcome  the  shortening  by  an  open  opera- 
tion and  continuous  traction  was  only  partly 
successful.  The  end  result  was  a  gain  of 
less  than  an  inch  in  the  length  of  the  limb. 
(Author's  collection.) 


Fig.  105. — Fracture  of  the  Lower  End  of  the 
Radius.  Slight  displacement  of  the  lower 
fragment  toward  the  radial  side.  (Author's 
collection.) 


Deformity. — Deformity  is  recognized  by  inspection,  palpation,  and  men- 
suration. In  order  properly  to  examine  a  fracture,  it  is  desirable  that  botli 
sides  of  the  body  should  be  exposed,  free  from  clothing,  so  that  the  appearance 
of  the  injured  limb  or  part  may  be  compared  with  that  of  the  sound  one.     The 


FRACTURES 


279 


limbs  should,  moreover,  be  in  identical  positions  with  respect  to  the  trunk,  and 
the  different  portions  of  each  limb  in  the  same  relations  with  respect  to  one 
another.  Only  in  this  manner  can  a  proper  comparison  be  made.  In  fractures 
of  the  upper  extremity  the 
shoulders  should  be  level, 
the  arms  abducted  to  the 
same  extent,  the  elbows 
flexed  to  the  same  degree, 
and  palms  pronated  or  su- 
pinated  to  the  same  degree. 
In  fractures  of  the  lower 
extremity  the  patient  must 
lie  flat  on  his  back  and  a 
line  drawn  through  the  an- 
terior superior  spines  of  the 
ilia  must  be  at  right  angles 
to  the  median  plane  of  the 
trunk,  the  legs  parallel  and 
as  near  together  as  possible, 
the  knee-  and  hip- joints  ex- 
tended. 

The  general  contour  of 
the  injured  limb  is  often  so 
changed  that  fracture  is  at 
once  suspected.  The  limb 
may  appear  bent  or  short- 
ened, and  broader  and  thick- 
er than  normal.  The  lower 
fragment  may  be  rotated 
through  gravity  or  muscular 
action.  A  distinct  promi- 
nence or  a  depression  may 
be  seen  where  a  level  surface 
should  exist,  or,  if  the  bone 
be  subcutaneous,  a  marked 
departure  from  its  normal  outline  may  be  quite  evident.  The  whole  extremity 
may  be  depressed,  and  fall  downward  or  inward  as  in  some  fractures  of  the  clavi- 
cle. It  goes  without  saying  that  a  thorough  knowledge  of  the  topographical  anat- 
omy of  the  part  is  indispensable  for  a  proper  appreciation  and  interpretation  of 
the  changed  relations  of  bony  landmarks  on  the  two  sides.  The  skin  may  be 
caught  and  held  by  the  sharp  point  of  a  bony  fragment.  The  attitude  of  the 
individual  may  even  be  quite  characteristic  in  certain  forms  of  fracture. 

Ecchymosis. — Ecchymosis  is  present  after  most  fractures,  but  may  not  ap- 
pear for  several  days.     It  often  appears  at  a  point  below  the  seat  of  fracture — 


Fig.  106. — Fracture  of  the  Radius  and  Ulna. 
(New  York  Hospital  collection.) 


280 


FKACTURES    AND   DISLOCATIONS 


near  the  elbow  in  fractures  of  the  upper  part  of  the  humerus,  in  the  foot  and 
ankle  in  fractures  of  the  leg.  In  fractures  of  the  forearm  and  leg  large  blebs 
containing  clear,  pink  or  bloody  serum  frequently  form  upon  the  skin  after 

the  first  twenty-four  hours.  In 
fractures  involving  joints  a  rapid 
effusion  of  blood  takes  place  into 
the  joint,  and  often  forms  a  prom- 
inent swelling  outlined  by  the 
attachments  of  the  joint  capsule. 
This  is  especially  notable  in  frac- 
tures of  the  patella.  The  inspec- 
tion of  the  limb  will  show  con- 
tusions, abrasions,  or  wounds,  so 
situated  that  a  probable  conclu- 
sion may  be  drawn  as  to  whether 
the  fracture  was  due  to  direct  or 
indirect  violence,  and  even  the 
probable  character  of  the  frac- 
ture— transverse,  oblique,  spiral, 
comminuted,  etc. — may  be  sur- 
mised. A  wound  communicating 
with  the  fracture  is  visible  at 
once.  A  pointed  fragment  of 
bone  may  even  be  seen  project- 
ing through  the  skin. 

By  palpation,  inequalities  in 
outline  of  the  suspected  bone  can 
often  be  appreciated ;  the  finger 
may  sink  into  a  crevice  between 
the  fragments.  If  much  edema 
exists  near  the  point  of  fracture  it 
may  sometimes  be  gently  pressed 
away  with  the  fingers,  and  the 
thickness  of  tissue  between  the 
surface  and  the  injured  bone 
thus  considerably  diminished. 
The  presence  of  extravasated  blood  will  give  rise  to  a  peculiar  sensation  of 
soft  crepitation  quite  unlike  that  produced  by  the  grating  of  bone.  By  palpa- 
tion, also,  the  character  of  the  displacement  and  the  shape  of  the  line  of  fracture 
may  be  made  out  in  those  bones  which  are  subcutaneous,  notably  in  the  clavicle 
and  in  the  tibia.  In  comminuted  fractures  the  number,  size,  and  shape  of  the 
fragments  may  sometimes  be  more  or  less  perfectly  estimated. 

Abnormal  Mobility. — A  point  of  false  motion,  as  it  is  called,  detected  in  a 
bone  where  such  motion  does  not  normally  exist,  is  positive  evidence  of  the 


Fig.  107. — Fracture  of  the  Olecranon  Process  op 
the  Ulna  with  Separation.  (New  York  Hospi- 
tal collection.) 


FRACTURES 


281 


presence  of  a  fracture.  In  some  situations  and  in  complete  fractures  the  recog- 
nition of  this  sign  is  entirely  simple.  This  is  the  case  with  most  fractures  of 
the  shafts  of  the  long  bones.  When,  however,  the  fracture  is  incomplete, 
impacted,  or  very  deeply  placed,  or  very  near  a  joint,  or  where  one  fragment 
is  very  small,  the  sign  may  be  absent,  or  difficult  or  impossible  to  obtain.  In 
bones  which  are  very  elastic — the  fibula  and  the  ribs,  for  example — a  feeling 
of  mobility  due  to  such  elasticity  may  be  mistaken  for  a  fracture. 

The  method  of  examination,  whereby  the  surgeon  seeks  to  obtain  this  sign, 
differs  in  different  bones  and  situations.  The  manipulation  should  be  con- 
ducted with  gentleness  in  order  to  avoid  inflicting  upon  the  patient  unnecessary 
pain  or  further  injury.  The  sign  is  most  easily  appreciated  in  fractures  of 
the  shaft  of  the  humerus  and 
of  the  femur.  The  surgeon 
grasps  the  limb  near  the  elbow, 
or  at  the  knee,  respectively,  and 
makes  slight  lateral  movements 
of  the  bone,  usually  the  abnor- 
mal mobility  is  appreciated  at 
once.  Where  two  bones  exist, 
as  in  the  forearm  and  in  the 
leg,  and  both  are  fractured  at 
nearly  the  same  level,  the  sign 
will  again  be  very  easy  to  obtain 
by  gentle  lateral  movements  of 
the  forearm  or  leg,  respectively. 
If  the  bones  are  broker  at  dif- 
ferent levels,  the  mobility  will 
be  less  marked,  but  will  never- 
theless be  easy  to  appreciate  in 
most  instances  by  manipulations 
similar  to  those  described. 

If  but  one  bone  of  the  fore- 
arm is  broken,  mobility  may 
generally  be  detected  in  the  fol- 
lowing way :  The  surgeon  grasps 
the  bone  between  the  fingers  and 
the  thumbs  of  either  hand,  the 
tips  of  the  fingers  being  sepa- 
rated an  inch  or  more;  he  then 
makes  slight  lateral  motions  as 
though  he  would  move  the  por- 
tions of  bone  grasped  between  the  fingers  of  either  hand,  one  upon  the 
other,  and  this  manipulation  is  carried  out  throughout  the  entire  length  of 
the  bone.     If  a  fracture  of  the  upper  portion  of  the  radius  is  suspected,  the 


Fig.  108. — Fracture  of  the  Tibia  and  Fibula. 
(New  York  Hospital  collection.) 


282 


FRACTURES    AND   DISLOCATIONS 


hand  grasps  the  elbow  with  the  thumb  upon  the  head  of  the  radius ;  with  the 
other  hand  the  surgeon  holds  the  hand  or  wrist  of  the  patient,  and  makes  gentle 
movements  of  pronation  and  supination.  If  the  head  of  the  radius  does  not 
rotate  beneath  the  thumb  during  these  movements,  the  radius  is  fractured. 

Complete  fractures  of  the  shaft  of  the  tibia  alone,  occurring  as  it  does  so 
commonly  by  indirect  violence  at  the  junction  of  the  middle  and  lower  thirds 

of  the  leg,  can  usually  be 
recognized  by  simple  man- 
ipulations. Fracture  of  the 
fibula  alone  may  or  may 
not  present  this  sign  in  an 
easily  recognizable  form. 
The  most  common  point  of 
fracture  in  the  fibula  is  a 
short  distance  above  the  ex- 
ternal malleolus,  produced 
by  indirect  violence  in  vio- 
lent abduction  of  the  foot; 
mobility  can  sometimes  be 
recognized  by  direct  pres- 
sure at  the  point  of  frac- 
ture. In  other  cases  the 
following  procedure  may  be 
used :  The  surgeon  places 
his  thumb  upon  the  tip  of 
the  external  malleolus,  and 
with  the  other  hand  presses 
upon  the  shaft  of  the  bone 
above  its  articulation  with 
the  astragalus  and  tibia.  The  fibula  may  be  felt  to  rock  to  an  abnormal  degree 
upon  the  astragalus,  so  that  the  upper  end  of  the  lower  fragment  is  felt  to 
move  outward,  or  the  pressure  upon  the  shaft  of  the  bone  is  gradually  shifted 
upward  upon  the  leg,  and  in  some  cases  it  will  be  found  that  when  a  certain 
level  is  reached  the  tip  of  the  malleolus  no  longer  moves. 

In  fractures  in  the  neighborhood  of  joints — the  upper  end  of  the  humerus, 
the  upper  part  of  the  femur,  and  the  upper  part  of  the  tibia — slight  rotary 
movements  of  the  shaft  of  the  bone  may  be  made  while  one  hand  grasps  the 
Tipper  end  of  the  bone,  above  the  supposed  point  of  fracture.  If  the  upper 
end  of  the  bone  does  not  follow  the  shaft,  a  fracture  is  present.  This  sign, 
of  course,  fails  in  incomplete  and  impacted  fractures ;  it  is  sometimes  of  great 
value  in  fractures  of  the  surgical  neck  of  the  humerus,  where  the  tuberosities 
are  grasped  with  the  fingers ;  rotary  movements  are  then  made  of  the  humerus 
by  grasping  the  elbow;  if  the  head  of  the  bone  is  attached  to  the  shaft  the 
tuberosities  may  be  felt  to  roll  back  and  forth  beneath  the  fingers.    In  fractures 


Fig.  109. — Old  Fracture  of  the  Patella,  Separation  of 
the  Fragments.  (New  York  Hospital,  service  of  Dr. 
Hartley.) 


FRACTURES  283 

of  the  condyles  of  the  humerus  and  of  the  femur,  or  when  a  small  portion  of 
bone  is  torn  away,  as  in  separation  of  the  greater  tuberosity  of  the  humerus, 
the  surgeon  strives  to  grasp  the  condyle  or  the  tuberosity,  as  the  case  may  be, 
and  move  it  in  the  plane  of  the  fracture  upon  the  shaft  of  the  bone. 

Crepitus. — Another  positive  sign  of  fracture  is  the  grating  sensation  felt  or 
sound  heard  when  two  fractured  bone  surfaces  are  moved  one  upon  the  other. 
In  order  that  this  sign  shall  be  present  it  is  not  only  necessary  that  the  fragments 
should  move  freely,  but  also  that  no  soft  tissue  should  intervene ;  consequently 
the  sign  is  absent  in  impacted  fractures,  in  fractures  with  longitudinal  separa- 
tion, and  in  cases  where  muscles,  tendons,  or  other  soft  parts  intervene.  It  is 
most  marked  in  fractures  of  the  shafts  of  the  long  bones  where  great  mobility 
exists,  in  comminuted  fractures,  and  in  general  where  the  other  positive  signs 
of  fracture  are  most  evident.  It  may,  however,  be  absent  or  hard  to  obtain 
in  oblique  fractures  with  much  overriding,  for  in  such  cases  the  soft  parts  may 
be  interposed ;  it  is  of  course  absent  in  all  incomplete  fractures.  Usually  the 
sign  is  elicited  by  the  same  manipulations  through  which  the  surgeon  seeks  to 
recognize  abnormal  mobility.  It  is  not  a  sign  which  should  be  sought  for 
persistently  and  by  means  of  extensive  and  strenuous  manipulations,  on  account 
of  the  clanger  of  producing  further  injury  to  the  soft  parts.  Occasionally 
crepitus  occurs  in  the  examination  of  a  fracture  as  a  loud,  sharp  click,  distinctly 
audible  to  bystanders.  More  often  it  is  simply  a  grating  sensation  felt  by  the 
surgeon's  fingers ;  it  may  be  mistaken  for,  or  confounded  with,  other  conditions : 
the  softer  grating  which  accompanies  separation  of  an  epiphysis  through  its 
cartilage ;  the  grating  which  occurs  in  joints  whose  cartilages  are  eroded  from 
disease ;  the  crepitation  of  subcutaneous  emphysema  accompanying  fractures 
of  the  ribs  or  wounds  of  the  pleura  and  lung ;  the  crepitation  of  inflamed  tendon 
sheaths  occurring  when  the  tendons  are  moved ;  the  crepitation  of  a  blood  clot. 
A  differentiation  of  these  various  forms  of  crepitation,  while  simple  enough 
in  most  instances,  is  possible  only  to  those  who  have  had  experience. 

Mensuration. — In  order  to  detect  the  presence  of  shortening  in  a  limb  or 
an  increase  in  circumference  or  in  diameter,  when  the  fracture  involves  the 
articular  extremities  of  certain  bones ;  measurements  with  a  tape  or  with  a 
pair  of  calipers  are  sometimes  used.  Such  measurements  are  only  approximate, 
and  cannot  be  made  with  absolute  accuracy  for  several  reasons.  It  is  rarely 
possible  to  apply  them  in  cases  of  suspected  shortening  to  the  extremities  of 
the  fractured  bone.  They  must  usually  be  taken  from  a  bony  point  upon  the 
trunk  to  another  bony  point  beyond  the  seat  of  fracture.  These  bony  points 
are  always  more  or  less  flat  or  rounded  surfaces  of  bone  covered  by  fat  and 
skin  movable  upon  the  bone  beneath ;  sometimes  the  exact  locality  of  such  a 
prominence  is  obscured  by  the  swelling  of  the  overlying  soft  parts. 

In  the  case  of  the  humerus,  the  tip  of  the  acromion  and  of  the  external 
condyle  of  the  humerus  are  the  points  between  which  the  measurements  are 
taken.  A  similar  measurement  is  taken  upon  the  opposite  side  of  the  body 
and  the  results  compared.     It  is  necessary  that  the  two  limbs  should  be  in  the 


284 


FRACTURES    AND   DISLOCATIONS 


same  position  relative  to  the  trunk  and  the  glenoid  fossa.  In  the  lower  extrem- 
ity the  measurements  are  made  from  the  anterior  superior  spine  of  the  ilium 
to  the  tip  of  the  external  malleolus.  The  spine  of  the  ilium  is  above  and  to  the 
outer  side  of  the  center  of  motion  at  the  hip-joint,  so  that  the  iliac  spine,  the 
center  of  motion  at  the  hip-joint,  and  the  external  malleolus  form  the  apices 
of  the  angles  of  a  triangle,  and,  according  as  the  lower  extremity  is  more  or 
less  abducted  or  adducted,  the  long  side  of  the  triangle — namely,  the  distance 
from  the  anterior  superior  spine  to  the  external  malleolus — will  vary  in 
length,  being  shorter  when  the  thigh  is  abducted  and  longer  when  the  thigh 
is  adducted  irrespective  of  whether  the  length  of  the  lower  extremity,  the 
other  long  side  of  the  triangle — namely,  the  distance  from  the  center  of  mo- 
tion at  the  hip- joint  to  the  external 
malleolus — varies  or  not. 


Fig.  110. — Fracture  of  the  Shaft  of  the  Fe-       Fig.  111. — Fracture  of  the  Shaft  of  the  Hu- 


mur  in  a  Female  Child  Aged  Ten.  Union 
with  overriding.  The  periosteal  bridges  along 
which  ossification  has  taken  place  are  well 
shown.  In  spite  of  the  marked  overriding  the 
functional  result  in  this  case  was  fairly  good. 
(X-ray  picture  by  the  author.) 


merus  in  a  Child,  Union  with  Overriding. 
Showing  periosteal  bridge  uniting  fragments. 
(X-ray  taken  by  the  author  six  weeks  after  the 
fracture  occurred.) 


Accordingly,  in  comparing  the  length  of  the  two  limbs,  it  is  necessary  that 
they  should  be  in  the  same  relative  position  in  respect  to  the  pelvis.  This  may 
be  accomplished  as  follows:  The  patient  is  placed  upon  his  back,  upon  a  level 
surface,  with  the  limbs  extended ;  a  cord  or  straight-edged  stick  is  laid  across 
the  anterior  superior  spines.  Midway  between  the  spines  a  string  is  fastened, 
and  extended  downward  between  the  feet  and  at  right  angles  to  the  stick  or 
string  crossing  the  spines.  The  internal  malleoli  are  then  placed  equidistant 
from  the  string  and  close  to  it;  measurement  may  then  be  made  from  the  spines 
to  the  external  malleoli  of  either  side,  and  then  compared.  With  the  utmost 
precautions,  an  error  of  half  a  centimeter,  or  even  more,  is  still  possible. 


FRACTURES 


285 


Another  source  of  error  is  based  upon  the  fact  that  in  many  persons  a  degree 
of  asymmetry  normally  exists  in  the  length  of  the  limbs  upon  the  two  sides  of 

the   body   of  which   the    individual    is   usually  

unconscious;   this  may  amount  to  an   inch   or 

more  in  the  lower  extremities.  A  further  error 
is  the  possible  existence  of  a  former  fracture, 
for  which  inquiries  should  always  be  made.  In 
fractures  involving  the  large  joints,  circumfer- 
ential measurements  of  the  joints  are  often  ren- 
dered inaccurate  by  the  presence  of  swelling. 
Increase  in  the  width  of  a  joint  is  best  detected 
by  the  use  of  a  pair  of  calipers  such  as  are  em- 
ployed by  obstetricians.  Thus  the  elbow,  the 
knee,  the  ankle  may  be  measured,  and  an  in- 
crease of  the  width  of  the  joint  detected  in 
some  fractures  of  the  condyles  of  the  humerus 
and  femur.  In  Pott's  fracture  of  the  ankle 
with  separation  of  the  fibula  and  tibia,  the  in- 
crease in  the  width  of  the  joint  may  be  quite 
marked. 

Subjective  Symptoms 


Fig.  112. — Fracture  of  the  Tibia 
axd  Fibula,  Union  with  Defor- 
mity. X-ray  taken  by  the  author 
one  year  after  the  injury  was  re- 
ceived. The  functional  result  was 
fair;  though  the  patient  still  com- 
plained of  pain  in  the  leg  while 
walking. 


the  limb   lies,    or   hangs,    as 


Loss  of  Function. — The  loss  of  function  ac- 
companying fracture,  although  nearly  always 
present  to  some  degree,  varies  much.  It  results 
from  mechanical  causes,  rarely  from  injuries 
to  nerve  trunks,  and  is  caused  or  increased  in 
many  instances  by  pain,  or  the  fear  of  pain. 
In  case  of  complete  fracture  of  the  femur  or 
humerus,  loss  of  function  is  usually  complete 
if  dead.  In  some  cases  of  fracture  loss  of  function  may  be  very  slight. 
I  have  known  an  intoxicated  man  to  walk  up  three  flights  of  stairs  with  a 
fractured  tibia  and  fibula,  from  which  injury  he  subsequently  died.  Prize 
fighters  have  been  known  to  continue,  and  even  win,  a  battle  with  a  fractured 
ulna.  Where  two  bones  exist,  as  in  the  forearm  and  leg,  the  loss  of  function, 
although  usually  present,  may  be  only  partial  or  slight.  Individuals  have 
walked  with  an  impacted  fracture  of  the  neck  of  the  femur  in  many  instances. 
It  is  to  be  remembered,  also,  that  other  injuries  than  fractures  may  produce 
loss  of  function. 

Pain. — Localized  pain  and  tenderness  is  present  in  nearly  all  cases  of  frac- 
ture ;  it  is  sometimes  slight  in  persons  who  have  locomotor  ataxia  and  some 
other  diseases  of  the  central  nervous  system,  and  may  be  obscured  by  delirium 
or  acute  alcoholism.  The  pain  of  fracture  is  elicited  by  pressure,  and  upon 
movement  of  the  fractured  bone.     Spontaneous  pain  may  be  moderate,  or  even 


286  FEACTUEES    AND   DISLOCATIONS 

absent,  as  long  as  the  part  is  kept  quiet.  Pain  is  elicited  by  pressure  at  the 
point  of  fracture  by  crowding  the  broken  surfaces  of  bone  together,  or  moving 
them  one  upon  the  other.  In  examining  superficial  bones,  finger  pressure  may 
be  used  at  successive  points  along  the  bone.  When  the  point  of  fracture  is 
reached  the  patient  almost  always  gives  evidence  of  severe  pain.  The  ends 
of  the  broken  fragments  may  be  crowded  together  in  the  long  axis  of  the  limb. 
In  fractures  of  the  ribs,  pressure  upon  the  sternum  often  gives  rise  to  pain  at 
the  point  of  fracture.  In  long,  slender,  and  elastic  bones,  like  the  fibula,  pres- 
sure upon  the  bone  by  squeezing  the  leg  may  give  rise  to  pain  at  the  fractured 
point.  The  patient  may  be  directed  to  make  voluntary  movements,  and  to 
contract  certain  sets  of  muscles  while  the  limb  is  held  in  a  fixed  position. 
Gentle  rotary  movements  of  the  limb  may  be  used.  Extreme  localized  pain 
and  tenderness  are  very  valuable  signs  of  fracture,  and  may  be  sufficient  in 
themselves  to  establish  the  diagnosis. 

The  History  of  the  Patient  and  of  the  Accident. — It  often  happens  that  a 
patient  who  has  suffered  a  fracture  has  been  so  disturbed  by  fear,  pain,  and 
emotional  excitement,  alcoholism,  or  the  unexpected  and  unobserved  character 
of  the  accident,  or  by  the  unconsciousness  or  shock  produced  by  the  associated 
injuries,  that  he  is  unable  to  give  any  intelligent  account  of  the  occurrence. 
On  the  other  hand,  he  may  be  able  to  describe  the  accident  so  that  the  surgeon 
may  know  that  the  fracture  was  caused  by  direct  or  indirect  violence  or  by 
muscular  action.  At  the  time  when  a  bone  is  broken  the  individual  may  hear 
or  feel  a  distinct  snap.  He  will  often  be  able  to  describe  changes  in  the  shape 
or  appearance  of  the  limb  following  the  accident,  and  the  degree  of  loss  of 
function  from  which  he  suffers.  A  history  of  previous  fractures  and  of  pre- 
disposing causes  to  fracture,  such  as  injury  or  disease  of  the  bones,  a  preexistent 
malignant  growth,  etc.,  can  be  sought  for,  and  sometimes  obtained.  The  diag- 
nosis will,  however,  in  general  depend  upon  the  objective  findings.  If  after 
ordinary  methods  of  examination  the  diagnosis  is  still  obscure,  a  general  anes- 
thetic may  be  administered ;  the  diagnosis  may  then  be  sometimes  verified  and 
the  fracture  dressing  applied  while  the  patient  is  still  unconscious.  It  is, 
however,  in  the  obscure  and  doubtful  cases  of  fracture  that  the  X-rays  find 
their  greatest  field  of  usefulness,  and  the  majority  of  obscure  fractures  or 
suspected  fractures  can  be  discovered  or  eliminated,  as  the  case  may  be,  by  a 
radiograph  or  a  series  of  radiographs,  to  the  satisfaction  of  the  surgeon  and 
the  patient. 

Complications  and   Couese  of  Fractures 

As  the  result  of  fractures,  and  during  their  repair,  certain  general  and  local 
complications  occur  the  recognition  of  which  is  important.  The  severity  of 
such  complications  varies  much  with  the  seat  and  character  of  the  fracture  and 
the  general  condition  of  the  individual. 

Delirium  Tremens. — In  the  alcoholic,  delirium  tremens  is  a  frequent  com- 
plication of  fractures.     The  symptoms  have  already  been  described  in  another 


FRACTURES  287 

chapter.  In  those  who  acknowledge  a  marked  alcoholic  habil  it  i-  probably 
wise,  after  fracture,  to  permit  the  patient  to  use  alcohol  in  moderate  quanti- 
ties, because  it  is  generally  believed  that  the  total  withdrawal  of  the  accustomed 
stimulant  may,  in  conjunction  with  the  injury,  bring  on  an  attack. 

Fat  Embolism. — Fat  may  frequently  be  found  in  the  urine  of  patients  suf- 
fering from  fracture  during  the  first  few  days  after  the  accident,  either  micro- 
scopically or  as  a  perceptible  film  of  fat  globules  floating  upon  the  surface  of 
the  urine.  It  is  rare,  however,  that  fat  enters  the  venous  circulation  from  the 
seat  of  fracture  and  reaches  the  capillaries  of  the  lungs  in  sufficient  quantity 
to  interfere  with  respiration.  The  serious  and  fatal  cases  which  have  been 
reported  have  occurred  in  from  twenty-four  hours  to  three  days,  rarely  as  late 
as  five  days,  after  the  accident.  The  symptoms  appear,  as  a  rule,  suddenly. 
They  are  dyspnea  with  hurried  and  labored  breathing,  paleness,  later  cyanosis 
of  the  skin,  the  physical  signs  of  edema  of  the  lungs,  sometimes  Cheyne-Stokes 
respiration  and  cough,  with  an  abundant  watery,  foaming  sputum,  sometimes 
tinged  with  blood.  Stupor  and  coma  soon  follow,  and  death  occurs  usually 
in  less  than  twenty-four  hours.  The  condition  can  hardly  be  mistaken  for 
shock,  which  follows  either  immediately  upon  the  injury  or  in  an  hour  or  two. 

Embolism  of  the  Lungs. — Embolism  of  the  lungs  from  the  dislodgment  of  a 
clot  in  an  injured  vein — whence,  passing  through  the  right  heart,  it  lodges  in 
the  pulmonary  artery — is  a  very  rare  complication  of  fracture,  and  usually 
results  in  almost  instant  death.  It  seldom  occurs  until  the  third  week  follow- 
ing the  fracture. 

Septicemia. — Septicemia  is  common  in  compound  fractures  which  become 
infected.  It  may  occur  in  fractures  originally  simple  which  become  compound 
by  protrusion  of  a  sharp  fragment  through  the  skin ;  in  fractures  by  direct 
violence  when  the  overlying  skin  is  so  severely  contused  that  it  sloughs ;  very 
rarely  in  simple  fractures  by  infection  through  the  blood  in  the  presence  of 
a  septic  focus  elsewhere  in  the  body.  Among  the  most  violent  and  rapidly 
fatal  forms  of  septic  poisoning  are  those  which  follow  compound  fractures  with 
extensive  laceration  of  the  soft  parts ;  for  example,  fracture  produced  by  a  load 
of  small  shot  fired  at  close  range ;  crushing  injuries  produced  by  the  wheels 
of  heavy  vehicles  in  which  infectious  material  is  ground  into  the  tissues ;  frac- 
tures produced  by  falls  from  a  height  in  which  the  bones  protrude,  and  perhaps 
enter  the  ground  or  are  extensively  soiled  by  dirt;  such  injuries  may  become 
infected  with  the  bacillus  of  malignant  edema,  the  Bacillus  aerogenes  capsu- 
latus,  or  with  the  Streptococcus  pyogenes  and  ordinary  saprophytic  bacteria. 

The  signs  and  symptoms  of  these  infections  have  already  been  described 
under  Diseases  of  Wounds.  Suffice  it  to  say,  that  in  severe  compound  fractures 
the  conditions  for  the  development  and  spread  of  these  infections  are  ideal.  It 
is  to  be  remembered  that  in  compound  fractures  in  certain  regions  air  may  be 
introduced  into  the  tissues  mechanically  and  cause  the  subcutaneous  crackling 
observed  on  palpation  when  gas  is  present  in  the  tissues.  In  these  cases  the 
constitutional  symptoms  and  local  signs  of  septic  infection  will  be  wanting. 


288  FRACTURES    AND   DISLOCATIONS 

Injuries  of  the  Blood-vessels. —  Compound  fractures  with  extensive  injuries 
to  the  soft  parts  are  sometimes  accompanied  by  contusion  or  laceration  of  large 
arterial  trunks.  The  diagnosis  can  sometimes  be  made  by  the  presence  of  pro- 
fuse arterial  hemorrhage  from  the  wound.  In  other  cases  the  crushing  and 
twisting  violence  may  have  sufficed  to  obliterate  the  lumen  of  the  artery,  or  to 
tear  it  in  two.  In  the  first  instance  the  diagnosis  may  be  made  by  finding 
the  bruised  vessel  without  pulsation,  often  stretched  or  twisted  in  the  wound, 
by  coldness  of  the  extremity  and  absence  of  pulsation  below  the  point  of  injury. 
Hemorrhage  may  occur  later  if  the  artery  sloughs,  or  gangrene  of  the  extrem- 
ity may  supervene.  Injury  of  large  arterial  trunks  is  less  common  in  simple 
fracture.  In  certain  situations  it  may  lead  to  dangerous  or  rapidly  fatal  re- 
sults. If  the  bleeding  takes  place  into  a  large  cavity — the  peritoneum  or  the 
pleura — it  may  be  fatal,  although  the  vessel  is  not  very  large. 

In  fractures  of  the  skull,  ruptures  of  the  internal  carotid  or  the  middle 
meningeal  are  usually  attended  by  rapidly  fatal  compression  of  the  brain.  Con- 
tusion of  a  large  artery  in  an  extremity  may  be  followed  by  thrombosis  and 
gangrene,  or  by  the  formation  of  an  aneurism  at  a  later  period.  If  the  artery 
is  completely  ruptured  and  bleeds  subcutaneously,  rapid  swelling  of  the  limb 
and  the  formation  of  a  more  or  less  well-defined  tumor  at  the  point  of  injury, 
which  pulsates  after  it  has  attained  a  certain  size,  accompanied  by  diminution 
or  loss  of  pulsation  distal  to  the  rupture,  suffice  to  make  the  diagnosis.  Pres- 
sure upon  the  veins  in  these  cases  may  be  sufficient  to  occlude  them,  and  gan- 
grene of  the  limb  results ;  such  gangrene  is  usually  of  the  moist  variety.  Rup- 
ture of  a  large  vein  in  simple  fractures  may  sometimes  be  inferred  from  the 
swelling  of  the  limb,  and  may  also  result  in  moist  gangrene.  The  gangrene 
following  fractures,  as  already  indicated,  may  involve  the  whole  extremity 
when  caused  by  destruction  of  the  main  vessels  of  the  limb  or  by  septic 
infection. 

Gangrene. — One  of  the  most  unfortunate  accidents,  both  for  the  surgeon 
and  his  patient,  is  gangrene  of  an  extremity  produced  by  the  improper  appli- 
cation of  dressings.  It  may  follow  the  application  of  a  circular  plaster  dress- 
ing to  a  recent  fracture,  insufficiently  padded  or  too  tightly  applied,  or  the 
application  of  a  circular  constriction  of  any  sort  about  the  limb,  an  ordinary 
bandage,  or  even  a  piece  of  sticking  plaster.  It  is  more  apt  to  follow  con- 
striction over  a  narrow  area  than  a  general  constriction  of  the  entire  limb. 
The  symptoms  are  an  undue  amount  of  pain,  swelling  and  blueness  of  the 
fingers  or  toes,  together  with  the  signs  of  sluggish  circulation  in  these  parts ; 
later,  coldness  and,  if  unrelieved,  the  signs  of  gangrene.  After  the  application 
of  a  fracture  dressing  such  as  might  possibly  cause  undue  constriction,  it  is 
the  duty  of  the  surgeon  to  inspect  the  limb  at  frequent  intervals  during  the 
first  forty-eight  hours,  to  examine  the  fingers  and  toes  with  care,  and  to  in- 
quire of  the  patient  as  to  sensations  of  pain  and  constriction. 

Localized  necrosis  of  tissue  or  gangrene  may  follow  injuries  of  the  soft 
parts  by  the  same  violence  which  produced  the  fracture,  or  the  pressure  of  an 


FRACTUEES  289 

unreduced  fragment  which  presses  against  or  has  partly  penetrated  and  re- 
mains caught  in  the  integument.  In  cases  of  contusion  and  laceration  of  the 
skin,  in  fractures  by  direct  violence  the  probable  area  of  necrosis  may  be 
estimated,  as  suggested  by  Stimson,  in  the  following  way:  The  limb  is  ren- 
dered bloodless  by  an  elastic  bandage  applied  as  for  the  performance  of  a 
bloodless  operation.  Those  portions  of  skin  which  do  not  share  in  the  general 
blush  which  follows  the  removal  of  the  constriction  will  probably  not  survive. 
This  holds  good  except  for  portions  of  skin  lying  distal  to  a  long  transverse 
wound  of  the  integument.  Such  areas  usually  remain  pale,  although  they  may 
still  survive. 

The  occurrence  of  localized  gangrene  may  be  recognized  by  the  dusky  red 
color  of  the  dead  tissues  which  is  not  changed  by  pressure,  by  the  signs  of 
more  or  less  acute  inflammation  in  the  surrounding  skin,  and  the  final  change 
of  the  dead  part  to  a  purple  and  then  to  a  black  color.  Such  necrosis  may  be 
aseptic,  in  which  cause  the  local  signs  of  inflammation  will  be  slight,  the  slough 
will  remain  dry,  and  the  wound  left  by  its  separation  clean  and  free  from  pus, 
or,  if  infected,  the  dead  tissues  may  or  may  not  emit  the  odors  of  putrefaction ; 
the  constitutional  symptoms  of  sepsis  will  usually  be  marked.  Incision  or 
operative  removal  of  the  dead  tissues  will  show  an  accumulation  of  thin,  usually 
brown  or  blood-stained  pus  in  the  deeper  tissues.  Careful  exploration  of  the 
wound  is  necessary  to  determine  the  extent  and  virulence  of  the  infection. 

Ischemic  Contractures  of  the  Muscles. — The  application  of  circular  constric- 
tion to  a  limb,  the  seat  of  fracture,  so  tight  as  to  seriously  interfere  with  the 
arterial  circulation  of  the  limb  but  not  sufficiently  to  produce  gangrene,  may 
be  followed  by  coagulation  of  the  muscle  plasma  and  degeneration  of  the  mus- 
cular fibers.  The  condition  is  most  common  as  the  result  of  tight  bandaging 
in  fractures  of  the  forearm.  The  muscles  undergo  a  true  rigor  mortis.  The 
fingers  become  stiff  and  flexed,  and  cannot  be  straightened.  Depending  upon 
the  severity  of  the  constriction  and  the  time  of  its  application,  the  muscles  may 
undergo  complete  or  partial  atrophy,  the  muscular  fibers  being  replaced  by 
fibrous  tissue.  The  condition  appears  soon  after  the  bandage  or  dressing  is 
applied,  and  is  to  be  recognized  by  an  undue  amount  of  pain  and  coldness  of 
the  fingers.  In  bad  cases  the  fingers  become  permanently  flexed  and  rigid  and 
the  limb  permanently  atrophied  and  useless.  In  less  severe  cases  some  motion 
may  be  regained  by  appropriate  treatment. 

Tetanus. — A  rare  complication  of  compound  fractures  is  tetanus.  It  fol- 
lows more  frequently  compound  fractures  in  those  regions  most  likely  to  be 
contaminated  with  the  soil — namely,  the  hands,  the  forearms,  less  commonly 
the  legs  and  feet.     The  symptoms  are  described  under  Tetanus. 

Pneumonia. — Pneumonia  is  not  a  very  rare  complication  of  fractures  in 
the  alcoholic  and  the  aged;  more  rarely  it  occurs  in  healthy  adults*  It  is  a 
very  serious  complication,  and  is  often  fatal.  In  ordinary  cases  it  comes  on 
a  few  days  after  the  injury,  and  is  apt  to  run  a  violent,  and  often  a  fatal,  course. 
The  pneumonia  may  be  a  broncho-pneumonia  or  a  lobar  pneumonia,  and  will 
20 


290  FRACTURES    AND    DISLOCATIONS 

give  the  characteristic  signs  and  symptoms.  In  old  persons  who  suffer  from 
fractures  and  are  confined  for  some  time  in  bed,  and  who  are  feeble,  hypostatic 
congestion  of  the  lungs  or  a  low  grade  of  pneumonia  of  the  dependent  portions 
of  the  lungs  not  infrequently  precedes  a  fatal  issue.  The  signs  and  symptoms 
of  the  pneumonia  are  not  usually  marked.  These  patients,  after  they  have 
been  in  bed  for  two  or  three  weeks,  gradually  become  weaker ;  they  may  have 
a  little  fever ;  they  are  often  mildly  delirious.  The  signs  of  pneumonia  in 
the  bases  of  the  lungs  may  be  discoverable  upon  physical  examination.  They 
gradually  lapse  into  unconsciousness  and  die.  Fractures  of  the  neck  of  the 
femur  in  old  people  are  often  followed  after  a  few  weeks  by  death  in  this  way. 

Injuries  of  the  Nerves. — A  nerve  trunk  may  be  contused,  stretched,  or  torn 
at  the  time  of  a  fracture,  or  may  be  pressed  upon  by  the  edge  of  a  bony  frag- 
ment or  by  the  formation  of  callus  or  new  bone,  or  may  be  included  in  the 
callus.  Rupture  or  severe  injury  of  a  nerve  may  be  inferred  from  the  loss  of 
function  and  sensation  in  the  part  supplied  by  the  nerve.  Owing  to  the  disuse 
of  the  limb  after  the  fracture,  such  an  injury  may  remain  unrecognized  for 
some  time.  In  case  the  loss  of  function  of  the  nerve  is  discovered  early,  it 
would  be  generally  unwise  to  assume  that  it  is  destroyed  unless  positive  evi- 
dences of  such  a  condition  exist.  The  nerve  may  be  only  bruised  or  stretched, 
under  which  circumstances  its  functions  will  return.  A  nerve  which  is  com- 
pressed by  an  edge  of  bone  or  by  an  excessive  callus  formation,  may  exhibit 
total  or  partial  loss  of  function,  or  may  become  the  seat  of  a  neuritis  accom- 
panied by  severe  pain.     (See  Injuries  of  JSTerves,  Vol.  III.) 

I  operated  successfully  upon  a  case  of  fracture  of  the  upper  third  of  the 
humerus,  in  which  there  was  an  excessive  amount  of  new  bone  on  the  inner 
surface  of  the  humerus  which  had  produced  pain  and  interference  of  function 
in  the  median  and  ulnar  nerves.  The  symptoms  disappeared  permanently 
after  the  operation.  The  musculo-spiral  nerve  is  sometimes  pressed  upon,  or 
even  included  in  the  callus  formation,  in  fractures  of  the  shaft  of  the  humerus. 
Symptoms  of  neuritis  or  partial  or  total  suspension  of  function  of  the  musculo- 
spiral  nerve  will  be  produced. 

Weakness  of  the  Callus. — As  the  result  of  local  and  general  causes,  a  frac- 
ture which  has  united  in  an  apparently  normal  way  may  gradually  undergo  a 
recurrence  of  deformity,  usually  angular,  as  the  result  of  use,  or  fracture  may 
take  place  through  the  callus  as  the  result  of  slight  degrees  of  violence.  Under 
such  circumstances,  in  the  absence  of  depressed  states  of  vitality  from  any  cause, 
we  may  assume  that,  owing  to  imperfect  reduction,  or  to  interposition  of  soft 
parts,  or  to  destruction  of  the  periosteum,  the  bridge  of  bone  between  the 
fragments  has  been  of  insufficient  strength.  If  a  fracture  occurs  the  signs  and 
symptoms  are  those  of  recent  fracture,  but  the  swelling,  pain,  etc.,  accompany- 
ing a  fresh  fracture  are  less  marked. 

Stiffness  of  the  Joints  following  Fracture. — Stiffness  of  the  joints  following 
fracture  is  observed  in  all  cases.  If  merely  due  to  disuse,  it  is  gradually 
recovered  from  by  active  use  of  the  limb.     In  the  aged,  or  in  rare  cases  where 


FRACTURES  291 

from  ignorance  and  fear  of  pain  the  individual  will  not  use  the  limb,  some 
limitation  of  motion  may  be  permanent.  In  fractures  accompanied  by  stretch- 
ing or  tearing  of  the  ligaments  of  a  joint  the  stiffness  may  be  more  marked, 
and  in  some  instances  a  chronic  arthritis,  or  even  arthritis  deformans,  may 
follow,  with  permanent,  partial,  or  complete  loss  of  mobility  in  the  joint.  In 
fractures  involving  the  articular  ends  of  bones  and  passing  into  joints,  such 
arthrites  are  fairly  common.  In  these  cases,  also,  a  mechanical  obstacle  to 
perfect  motion  in  the  joint  may  exist  by  reason  of  the  changed  relations  due 
to  unreduced  displacements  or  to  the  formation  of  callus  and  new  bone. 

Disturbances  of  Nutrition. — Following  all  fractures  there  is  a  certain  amount 
of  disturbance  in  the  nutrition  of  the  limb.  The  muscles  are  diminished  in 
size.  The  limb  is  often  swollen  and  blue ;  such  signs  are  usually  more  marked, 
and  last  longer  in  fractures  of  the  leg.  In  uncomplicated  cases  they  are  re- 
covered from  after  a  variable  time,  depending  upon  the  local  and  general 
conditions. 

Faulty  and  Fibrous  Union. — When  broken  bones  unite  in  such  a  manner 
that  marked  deformity  or  functional  disability,  or  both,  remain  as  the  result 
of  the  permanent  displacement  of  the  broken  bones,  the  condition  is  spoken  of 
as  faulty  or  vicious  union,  implying  usually  absence  of  or  imperfect  treatment. 
Such  deformities  are,  of  course,  of  a  very  varied  character,  are  easy  to  recog- 
nize, and  need  no  special  description  in  this  place.  (See  Regional  Surgery.) 
When  fractured  bones  unite  by  fibrous  tissue  merely,  not  by  bone,  an  abnormal 
mobility  remains  at  the  point  of  fracture  readily  appreciated  on  manipulating 
the  limb,  and  an  actual  space  or  separation  can  sometimes  be  detected  between 
the  fragments,  notably  in  fractures  of  the  olecranon  and  fractures  of  the 
patella.     The  condition  is  known  as  fibrous  union. 

Period  Required  for  the  Union  of  Fractures. — While  no  accurate  estimate 
of  the  time  required  for  the  union  of  fractures  can  be  made,  the  general  average 
may  be  given  as  follows : 


&' 


Metacarpal  or  metatarsal  bones  as  well  as  ribs.  .  3  weeks. 

Clavicle  4  " 

Forearm 5  " 

Humerus  and  fibula 6  " 

Surgical  neck  of  humerus  and  tibia 7  " 

Tibia  and  fibula  together 8  " 

Femur 10  " 

Neck  of  Femur 12  " 

(E.  Gurlt's  statistics.) 

Delayed  Union  and  Failure  of  Union. — Comminuted  fractures  usually  re- 
quire a  longer  time  for  complete  consolidation,  and  compound  fractures,  if 
infected,  may  take  very  long  indeed.  When  the  normal  time  for  the  union 
of  a  fracture  has  been  considerably  exceeded,  the  condition  is  spoken  of  as 
delayed  union,  and  if  union  entirely  fails  after  a  considerable  lapse  of  time, 


292 


FRACTURES    AND   DISLOCATIONS 


the  condition  is  known  as  failure  of  union.  In  certain  situations,  notably  in 
the  patella,  the  olecranon,  and  in  sonie  fractures  of  the  neck  of  the  femur, 
bony  union  seldom  if  ever  takes  place  without  operative  interference,  and  in 
these  cases  we  speak  simply  of  fibrous  union.  The  persistence  of  abnormal 
mobility  is  the  characteristic  sign  of  "  delayed  "  or  "  failure  of  union."  When 
the  fracture  is  in  the  immediate  vicinity  of  a  joint,  the  mobility  may  be  hard 
to  make  out  by  physical  examination ;  pain  and  disturbance  of  function  will 
be  present,  and  a  carefully  taken  X-ray  picture  will  generally  make  the  diag- 
nosis clear.  In  recently  united  fractures  the  callus,  or  new  bone,  casts  a 
shadow  less  dense  than  the  shadows  cast  by  the  original  fragments,  but  dense 
enough  to  be  clearly  seen  as  a  bridge  passing  from  one  fragment  to  the  other. 
When  the  shadow  of  the  callus  can  be  observed,  even  though  faint,  passing 
from  one  fragment  to  the  other,  the  prognosis  of  ultimate  union  is  favorable. 
In  many  cases  of  failure  of  union,  notably  of  the  bones  of  the  forearm,  with 
loss  of  substance,  the  shadow  of  the  callus  is  entirely  absent,  or  some  callus 
may  be  evident  around  the  end  of  one  fragment  and  none  around  the  other. 
Where  no  callus  at  all  can  be  seen  after  several  months  the  chances  of  bony 
union  without  operative  intervention  are  very  poor.  In  other  cases  atrophic 
changes  can  be  seen  to  have  taken  place  in  the  ends  of  the  fragments ;  again  the 
outlook  is  unfavorable. 

Displacements. — The  displacements  of  the  bony  fragments  were  classified 
by  Malgaigne  into  six  classes.     One  or  several  of  these  kinds  of  displacement 


Fig.  113. — Fracture  of  the  Tibia  and  Fibula,  Union  with  Extreme  Displacement. 
(New  York  Hospital  Museum.) 


may  exist  in  the  same  fracture.     They  are,  according  to  Stimson  (L.  A.  Stim- 
son,  loc.  cit.,  page  34),  as  follows:  The  displacements  may  be  in 

1.  The  transverse  axis  of  the  bone — transverse  or  lateral  displacement. 

2.  The  long  axis  of  the  bone — angular  displacement. 


FRACTURES 


293 


3.  The  circumference  of  the  bone — rotary  displacement. 

4.  The  length  of  the  bone — overriding. 

5.  Penetration  of  one  fragment  by  the  other — impaction  and  crushing. 

6.  Direct  longitudinal  separation. 

Stimson  adds  a  seventh  class  of  irregular  displacements,  among  them  the 
interposition  of  a  bone  between  the  bony  fragments  of  another.  Rotation  of 
a  fragment  upon  its  transverse  axis — as  in  some  fractures  of  the  neck  of  the 
humerus.  Crossing  of  the  fragments  like  the  letter  X  in  some  fractures  of  the 
clavicle.  Interposition  of  the  end  of  the  shaft  between  the  separated  condyles 
— femur  and  humerus. 

1.  Transverse  or  Lateral  Displacement. — The  fragments  are  dis- 
placed completely  or  partially  in  a  direction  at  right  angles  to  the  long  axis 
of  the  bone.  When  this  displacement  is  complete,  it  rarely  exists  except  in 
combination  with  one  of  the  other  forms — angular,  overriding,  or  rotary. 

2.  The  Long  Axis  of  the  Bone — Angular  Displacement. — Angular 
displacement  occurs  in  complete  and  incomplete  fracture,  notably  of  the  shafts 
of  the  long  bones.     It  may  be  present  to  any  degree,  from  the  production  of  a 


Fig.  114. — Fracture  of  the  Femur,  Union  -with  Displacement.     (New  York  Hospital  Museum.) 

slight  angular  deflection  at  some  point  in  the  bone,  to  a  sharp  bend  at  a  right 
angle,  or  even  more.  In  the  long  bones  it  is  very  easy  to  recognize  if  well 
marked,  but  at  the  ends  of  the  long  bones  near  the  joints,  and  in  short  bones, 
notably  when  combined  with  crushing  or  impaction,  its  existence  may  be  diffi- 
cult to  determine  without  the  use  of  the  X-rays. 

3.  The  Circumference  of  the  Bone — Botary  Displacement. — This 
form  of  displacement  occurs  when  one  of  the  bony  fragments,  usually  the  one 
farthest  from  the  trunk,  rotates  about  its  long  axis,  while  the  other  fragment 
retains  its  normal  relations.  It  occurs  most  often  as  the  result  of  gravity  or 
of  muscular  action  in  fractures  of  the  long  bones,  notably  of  the  shaft  of  the 
femur,  of  both  bones  of  the  leg,  and  in  fractures  of  the  radius. 

4.  Overriding. — Overriding  is  a  very  common  form  of  displacement  in 
fractures  of  the  shafts  of  the  long  bones,  notably  when  the  lines  of  fracture 
are  oblique ;  it  also  occurs  in  transverse  fractures  combined  with  lateral  and 
angular  displacement.     It  produces  shortening  of  the  injured  segment  of  the 


294 


FEACTUEES    AND   DISLOCATIONS 


limb,  except  where  one  of  the  bones  remains  intact,  when  shortening  may  be 
absent.      Overriding  is  produced  by  a  continuance  of  the  violence  after  the 

fracture  has  occurred,  by  muscular  action, 
and  by  the  swelling  of  the  limb  follow- 
ing the  fracture,  as  the  result  of  the  ten- 
sion of  the  tissues,  the  circumference  of  the 
limb  being  increased  at  the  expense  of  its 
length. 

5.  Penetration,  Impaction,  ok  Crush- 
ing.— This  form  of  displacement  occurs 
when  one  bony  fragment  is  driven  into  or 
penetrates  the  other.  It  is  very  common  at 
the  upper  end  of  the  femur,  fractures  of  the 
neck,  and  at  the  upper  end  of  the  humerus, 
lower  end  of  the  radius,  and  in  general 
where  the  compact  shaft  of  a  long  bone  joins 
its  spongy  extremity.  Crushing  is  common 
in  the  short  spongy  bones,  such  as  the  os 
calcis.  The  degree  of  impaction  of  one 
fragment  into  another  varies  greatly ;  it 
may  be  so  slight  as  to  be  broken  up  dur- 
ing a  gentle  examination ;  it  often  happens 
that  the  impacted  fragments  are  separated 
during  efforts  made  to  overcome  the  dis- 
placement; in  other  instances  the  impac- 
tion is  so  firm  that  the  condition  cannot 
be  overcome  by  ordinary  means,  and  is 
permanent. 

6.  Direct  Longitudinal  Separation. 
— This  form  of  displacement  is  compara- 
tively rare,  and  occurs  in  but  few  situa- 
tions, notably  in  fractures  of  the  patella, 
of  the  olecranon  process  of  the  ulna,  and 
sometimes  in  fractures  of  the  shaft  of 
the  humerus,  below  the  insertion  of  the 
deltoid    by    the    action    of    gravity    when 

the  elbow  and  forearm  are  not  supported.  In  fractures  of  the  patella  and 
olecranon,  the  separation  is  maintained  by  muscular  action,  and  by  the 
tension  of  the  joint  capsule  from  effused  blood. 


Fig.  115.  —  Fracture  of  the  Radius 
and  Ulna.  Failure  of  union.  Note 
the  atrophy  in  the  upper  end  of  the 
lower  fragment  of  the  ulna.  In  this 
case  repeated  operations  in  the  effort 
to  bring  about  union  between  the 
bones  failed.  Case  of  Dr.  F.  T.  Brown. 
(X-ray  by  the  author.) 


DISLOCATIONS 

A  dislocation  is  a  permanent  separation  of  joint  surfaces  of  bones  nor- 
mally in  contact.     The  separation  may  be  complete  or  partial.     Complete  dis- 


DISLOCATIONS  295 

location  when  the  joint  surfaces  are  entirely  separated  or  touch  only  at  their 
edges,  or  partial  (subluxation)  when  some  part  of  the  joint  surfaces  still  remain 
in  contact.  When  by  rupture  or  stretching  of  joint  ligaments  the  joint  sur- 
faces are  separated,  but  return  immediately  to  their  normal  relations,  the  con- 
dition is  called  a  sprain  or  distortion.  Dislocations  are  designated  by  the 
name  of  the  joint  whose  bones  are  displaced,  or  by  the  name  of  the  distal 
bone  or  bones  forming  the  articulation.  Thus  we  may  speak  of  a  dislocation 
of  the  shoulder  or  hip  as  a  dislocation  of  the  humerus  or  femur,  respectively. 
When  both  ends  of  the  same  bone  are  dislocated,  the  condition  is  sometimes 
called  a  total  dislocation.  By  diastasis  is  meant  a  direct  tearing  apart  of  the 
bones,  as  in  separation  of  the  pubic  bones  at  the  pubic  symphysis  or  separa- 
tion of  bones  along  a  line  of  suture,  as  in  separation  of  the  bones  of  the  skull. 
A  compound  dislocation  is  associated  with  a  wound  communicating  with  the 
external  air.  A  complicated  dislocation  is  associated  with  a  fracture,  or  with 
injuries  of  the  soft  parts,  blood-vessels,  nerves.  Dislocations  may  be  trau- 
matic, congenital,  or  pathological  (spontaneous,  inflammatory  dislocation). 
The  first  are  the  result  of  sudden  violence.  The  second  occur  during  intra- 
uterine life  from  imperfect  development  of  the  joint  structures,  and  the  third 
occur  as  the  result  of  disease  of  the  bones  or  the  joints  themselves,  sometimes 
as  the  result  of  diseases  of  the  spinal  cord.  These  may  be  sudden  or  gradual 
in  their  production. 

Traumatic  Dislocations. — Dislocations  are  much  less  frequent  injuries  than 
fractures,  the  proportion  being  about  one  to  ten.  They  may  occur  at  any 
period  of  life.  Dislocations  are  more  common  in  the  upper  extremity  than 
the  lower.  The  shoulder  is  most  often  dislocated,  the  joints  of  the  fingers 
next,  the  elbow  next.1  Stimson's  statistics  of  the  dislocations  occurring  in  the 
Hudson  Street  Hospital  in  New  York,  1894-99,  showed  that  out  of  705  dis- 
locations, 27  were  of  the  lower  extremity,  and  of  these,  9  were  of  the  hip, 
8  of  the  knee;  633  were  of  the  upper  extremity,  and  of  these,  287  of  the 
shoulder,  67  of  the  elbow,  175  of  the  metacarpo-phalangeal  and  phalangeal 
joints;  45  were  of  the  head  and  trunk,  and  of  these,  41  of  the  lower  jaw  and 
3  of  the  vertebra?.  Traumatic  dislocations  may  occur  as  the  result  of  direct 
or  indirect  external  violence  or  from  violent  muscular  action. 

Dislocations  by  Direct  Violence. — Dislocations  due  to  direct  violence 
are  infrequent;  they  occur  when  the  force  is  applied  directly  to  the  articular 
end  of  one  of  the  bones  forming  the  joint,  whereby  it  is  simply  forced  directly 
away  from  the  other  bone.  It  does  not  usually  occur  from  an  exaggeration 
of  some  normal  movement  of  the  joint,  but  often  in  a  direction  in  which  the 
joint  has  no  normal  movement  at  all,  frequently  in  a  direction  parallel  with 
the  plane  of  the  joint  surfaces.  Owing  to  the  considerable  force  necessary 
to  produce  a  dislocation  by  direct  violence,  fractures  are  a  common  com- 
plication. 

1  L.  A.  Stimson.     "Fractures  and  Dislocations,"  3d  edition,  p.  407.     Lea  Bros. 


296  FRACTURES    AND   DISLOCATIONS 

Dislocations  by  Indirect  Violence. — The  force  is  applied  at  some  dis- 
tance from  the  joint,  either  to  the  shaft  of  the  hone,  to  its  other  end,  or 
through  the  medium  of  other  hones.  The  violence  may  act  in  a  variety  of 
ways.  It  may  be  applied  directly  in  the  long  axis  of  the  hone,  so  that  its 
articular  surface  is  simply  caused  to  slide  away  from  that  of  the  other  hone 
forming  the  joint,  the  limb  being  at  the  time  in  a  position  favorable  for  such 
an  occurrence.  More  commonly  the  mechanism  is  one  of  leverage;  the  force 
acts  upon  the  shaft  of  the  bone  forming  the  long  arm  of  the  lever  to  produce 
an  exaggeration  of  some  normal  motion  until  finally  checked  by  a  bony  promi- 
nence or  the  tension  of  a  ligament;  the  force  continuing  to  act,  the  bony 
prominence  or  the  ligament  becomes  a  fulcrum,  and  later  a  center  of  motion 
about  which  the  articular  extremity  of  the  bone — the  short  arm  of  the  lever — 
continues  to  move  until  the  joint  surfaces  are  pried  apart.  In  other  cases  the 
violence  acts  to  produce  motion  in  the  joint  in  a  direction  in  which  no  motion 
normally  occurs,  or  only  to  a  limited  extent,  or  only  in  certain  positions  of  the 
joint.  Such  motions  are  not  infrequently  motions  of  abduction,  adduction,  or 
rotation.  Examples — the  knee,  ankle,  elbow.  In  order  to  produce  dislocations 
in  this  manner  considerable  degrees  of  violence  are  required,  and  associated 
injuries  of  the  bones  and  soft  parts  are  common. 

Dislocations  by  Muscular  Action. — Dislocations  due  to  muscular  vio- 
lence are  comparatively  rare;  they  most  frequently  occur  as  the  result  of  the 
violent  convulsive  movements  accompanying  hysteric,  uremic,  or  other  convul- 
sions ;  their  mechanism  in  this  case  may  be  either  that  of  indirect  or  direct 
violence — that  is  to  say,  the  violent  motion  may  carry  the  limb  beyond  its  nor- 
mal range,  so  that  a  leverage  occurs,  the  joint  surfaces  are  pried  apart,  and  dis- 
location results;  or,  on  the  other  hand,  a  certain  set  of  muscles  may  act  vio- 
lently upon  the  head  of  the  bone,  cause  rupture  of  the  ligaments  of  the  joint 
and  dislocation. 

Kecurrent  or  Habitual  Dislocations. — It  occasionally  happens  that 
traumatic  dislocations  of  a  joint,  usually  the  shoulder,  but  sometimes  other 
joints,  recur,  from  time  to  time,  from  slight  degrees  of  mechanical  violence. 
Such  conditions  are  due  to  imperfect  repair  of  ruptured  ligaments  or  muscles, 
or  from  a  fracture  of  the  rim  of  a  glenoid  cavity  which  has  resulted  in  deform- 
ity, or  which  has  been  imperfectly  repaired.  In  such  cases,  also,  the  capsule  of 
the  joint  may  be  relaxed,  imperfect,  or  extensively  stretched.  A  similar  condition 
may  be  produced  by  the  paralysis  or  atrophy  of  muscles  surrounding  a  joint. 

Complications  Attending  Dislocations. — The  complications  attending  dislo- 
cations are  many  and  serious. 

Fracture  of  the  Dislocated  Bone. — Among  these  complications  is  frac- 
ture of  the  dislocated  bone,  either  of  its  entire  shaft  close  to  the  dislocated  end, 
or  of  the  tearing  away  of  portions  of  the  head  of  the  bone  by  muscles,  tendons, 
or  ligaments. 

Injuries  to  the  Blood-vessels. — The  injury  of  the  main  blood-vessel 
of  a  limb  is  uncommon  as  the  result  of  a  simple  dislocation.     If  the  main 


DISLOCATIOXS  297 

artery  of  the  limb  is  torn  or  severely  stretched,  a  traumatic  aneurism  may  form 
immediately  or  later,  or  gangrene  of  the  limb  may  result.  The  artery  usually 
involved  has  been  the  axillary  in  anterior  and  internal  dislocations  of  the 
shoulder.  The  danger  of  gangrene  is,  of  course,  greater  if  the  main  vein  of 
the  limb  is  also  injured. 

Injuries  of  the  Xeeves. — Injuries  of  the  nerves  may  be  produced  directly 
by  the  same  violence  which  caused  the  dislocation,  or  they  may  occur  by  the 
pressure  of  the  displaced  head  of  the  bone.  The  symptoms  will  vary  according 
as  the  nerve  trunk  is  actually  torn  across,  or  is  merely  contused,  stretched,  or 
compressed.  In  the  first  instance,  the  symptoms  will  be  immediate  and  com- 
plete loss  of  sensation  and  motion  in  the  area  supplied  by  the  nerve.  If  the 
injury  to  the  nerve  has  been  incomplete,  the  symptoms  will  consist  of  partial, 
sensory,  or  motor  paralysis,  followed  later  in  certain  instances  by  neuritis, 
which  may  extend  to  other  nerves. 

It  may  be  well  to  remark  here  that  in  every  case  of  dislocation  it  is 
the  duty  of  the  surgeon,  as  well  to  the  patient  as  to  himself,  to  examine 
carefully  for  the  signs  of  injury  to  important  blood-vessels,  as  indicated  by 
weakness  or  absence  of  pulsation  in  the  peripheral  arteries,  sudden  or  excessive 
swelling  in  the  neighborhood  of  the  dislocated  joint,  or  swelling  of  the  limb; 
paralysis  of  motion  or  sensation  in  the  extremity.  This  examination  should 
precede  the  efforts  at  reduction,  and  the  patient's  attention  should  be  called 
to  the  existence  of  any  of  these  abnormalities,  if  found,  in  order  that  the  con- 
dition may  not  subsequently  be  regarded  by  the  patient  as  the  result  of  the 
treatment.  Dislocations  may,  furthermore,  when  they  occur  in  bones  close 
to  the  trunk,  cause  pressure  upon  important  structures,  and  dangerous,  or  even 
fatal  symptoms.  Dislocation  of  the  inner  end  of  the  clavicle  may  cause  pres- 
sure upon  the  trachea  and  esophagus. 

Compound  Dislocations. — Compound  dislocations  are  usually  caused  by  ex- 
treme degrees'  of  violence.  The  laceration  of  the  muscles,  of  other  soft  parts, 
and  of  the  skin  are  usually  produced  by  the  violence  which  caused  the  dislo- 
cation continuing  to  act,  thus  forcing  the  bones  from  within  outward  through 
the  tissues.  They  are  rare,  and  occur  oftener  in  the  knee,  elbow,  ankle,  and 
phalanges  than  elsewhere.  The  coexistence  of  lacerated  wounds  of  the  soft 
parts,  and  of  a  wound  opening  into  the  interior  of  a  joint  thereby  exposed  to 
infection,  together  with  the  not  infrequently  associated  injury  of  important 
blood-vessels  in  these  cases,  renders  the  compound  dislocation  of  a  large  joint 
a  very  grave  injury  indeed. 

Diagnosis  of  Dislocations. — The  signs  and  symptoms  whereby  we  recognize 
the  presence  of  a  dislocation  are  partly  objective  and  partly  subjective,  such  as 
can  be  observed  by  the  surgeon,  and  those  of  which  the  patient  himself  is  cog- 
nizant. The  former  consist  of  deformity,  of  limitation  of  motion,  of  crepitus. 
The  subjective  symptoms  consist  of  pain,  of  loss  of  function,  and  of  the  history 
of  the  accident.  While  the  diagnosis  of  many  dislocations  can  be  made  at  a 
glance,  sometimes  from  the  mere  attitude  or  gait  of  the  patient,  yet  certain 


298  FRACTURES    AND   DISLOCATIONS 

dislocations,  notably  when  accompanied  by  much  swelling  from  extravasated 
blood,  and  those  complicated  by  fracture,  offer  very  great  difficulties.  As  in 
fractures,  it  is  desirable  that  the  patient  should  be  so  far  unclothed  that  both 
sides  of  the  body  may  be  examined  and  compared.  It  is  often  desirable  that  the 
patient  should  be  prepared  to  take  an  anesthetic.  The  examination  of  dislo- 
cations and  their  reduction  is  often  painful. 

Differential  Diagnosis. — The  differential  diagnosis  between  disloca- 
tions and  fractures  in  the  neighborhood  of  joints  can  often  be  made  more  read- 
ily when  the  patient  is  under  an  anesthetic  and  the  muscles  are  entirely  relaxed. 
The  abnormal  position  assumed  and  maintained  by  the  head  of  a  dislocated 
bone  does  not  depend  upon  the  spasmodic  or  tonic  contractions  of  muscles, 
but  upon  the  tension  of  ligaments  or  of  untorn  portions  of  the  joint  capsule, 
and  upon  the  mechanical  relations  of  the  displaced  bones.  A  deformity  due 
to  muscular  action,  or  maintained  thereby,  disappears  under  a  general  anes- 
thetic, not  so  the  deformity  of  a  dislocation.  As  already  noted,  the  examination 
should  include  a  determination  of  whether  injuries  of  blood-vessels  or  nerves 
are  present.     In  cases  where  doubts  exist  the  X-rays  should  be  used. 

History. — In  the  diagnosis  of  dislocations  it  is  very  important  to  learn 
if  possible  the  position  of  the  limb  at  the  time  of  the  accident,  the  manner  in 
which  the  force  was  exerted,  the  position  which  the  limb  assumed  immediately 
after  the  accident,  and  whether  this  position  has  been  maintained  or  has  changed 
to  some  so-called  secondary  position.  It  is  very  desirable  to  know  how,  in 
what  direction,  and  at  what  point  the  bone  left  its  socket,  and  tore  through 
the  capsule  of  the  joint,  because  the  manipulations  for  the  purpose  of  reduction 
will  depend  largely  upon  a  knowledge  of  these  data. 

Soon  after  the  occurrence  of  a  dislocation  swelling  takes  place  in  the  neigh- 
borhood of  the  joint  from  effused  blood.  Ecchymosis  will  follow,  but  does  not 
usually  reach  the  surface  for  hours  or  days.  If  the  dislocation  has  been  caused 
by  direct  violence  there  will  be  the  evidences  of  contusion. 

Inspection. — By  inspection,  also,  the  position  of  the  limb  is  to  be  com- 
pared with  that  of  the  normal  side ;  this  is,  in  general,  a  most  valuable  aid  in 
the  diagnosis ;  in  many  instances  it  is  so  entirely  typical  as  to  render  the  pres- 
ence of  a  dislocation  quite  certain.  A  departure  from  this  rule  occurs  in  those 
so-called  atypical  dislocations  in  which  the  ligaments  which  hold  the  dislocated 
bone  in  its  abnormal  position  have  been  extensively  torn.  One  of  the  characters 
to  be  noted  is  that  the  long  axis  of  the  bone  is  not  directed  toward  its  proper 
position  in  the  joint,  but  to  one  side  of  the  same.  Frequently  it  is  possible  to 
see  that  the  prominence  normally  created  by  the  head  of  the  bone  is  lost,  and 
that  a  depression  exists  in  its  place.  The  head  of  the  bone  in  its  new  situation 
may,  on  the  other  hand,  cause  a  visible  swelling. 

The  apparent  or  real  shortening  or  lengthening  to  be  noted  in  some  dis- 
locations is  not  as  valuable  a  sign  as  it  is  in  fractures  for  several  reasons:  First, 
it  is  not  usually  possible  in  dislocations  to  place  the  two  limbs  in  the  same 
relative  position  in  respect  to  the  trunk,  and,  as  has  been  pointed  out  in  the  case 


DISLOCATIONS  299 

of  fractures,  this  is  essential  to  correct  comparative  measurements.  Second,  the 
proximal  bone  is  frequently  held  in  a  more  or  less  fixed  position  by  the  volun- 
tary contraction  of  the  muscles,  and  such  a  position,  tilting  of  the  pelvis  or 
of  the  scapula,  for  example,  may  make  the  limb  appear  lengthened  or  short- 
ened, as  the  case  may  be. 

Palpation. — The  most  valuable  objective  signs  are  to  be  determined  by 
palpation — namely,  the  actual  recognition  of  the  head  of  the  bone  and  its 
relation  to  the  joint  cavity.  No  amount  of  pains  should  be  spared  to  accom- 
plish this,  for  without  it  the  diagnosis  of  dislocation  is  often  incomplete.  The 
head  of  the  bone  may  often  be  grasped  between  the  examining  fingers  and  its 
contour  recognized.  In  deeply  placed  bones  this  cannot  always  be  accomplished. 
An  effort  should  also  be  made  to  feel  with  the  fingers  that  the  cavity  where 
the  head  of  the  bone  belongs  is  empty.  The  position  of  the  head  of  the 
bone  may,  however,  often  be  inferred  from  the  attitude  of  the  limb,  abduction, 
adduction,  rotation,  or  from  the  position  of  some  bony  prominence,  the  rela- 
tions of  which  to  the  head  of  the  bone  are  known,  the  external  condyle  of  the 
humerus,  for  example,  in  dislocations  of  the  head  of  the  radius.  If  the  head 
of  the  bone  is  once  found,  its  identity  may  be  established  by  finding  that  it 
participates  in  motions  communicated  to  the  shaft.  When  great  swelling 
exists  the  use  of  a  general  anesthetic  greatly  facilitates  the  examination,  and 
enables  the  surgeon  to  push  away  the  extravasated  blood  and  to  diminish  the 
edema  by  pressure,  so  that  the  extremity  of  the  bone  can  be  more  readily  felt. 

Steeeoscopic  Radiographs. — As  in  fractures,  stereoscopic  radiographs 
afford  great  assistance  in  the  diagnosis  of  doubtful  cases  of  dislocation,  and 
especially  of  dislocation  complicated  by  fracture.  Owing  to  the  presence  of 
large  amounts  of  extravasated  blood  and  to  the  occasional  difficulty  of  arrang- 
ing the  dislocated  joint  in  a  proper  relation  to  the  tube,  and  to  the  photo- 
graphic plate,  excellent  pictures  are  not  always  easy  to  obtain,  but  they  can 
usually  be  made  sufficiently  good  to  establish  the  diagnosis  clearly. 

Limitation  of  Motion. — The  position  of  the  rent  in  the  capsule  and 
the  relation  of  the  dislocated  head  to  the  untorn  and  tense  ligaments  is  found 
to  vary  in  a  typical  and  definite  manner  in  the  different  varieties  of  dislocation. 
Any  motion  tending  to  increase  the  tension  of  the  ligaments  is  resisted ;  other 
motions,  notably  those  which  relax  the  stretched  ligaments,  can  still  be  made. 
This  resistance  to  motion  in  certain  directions  and  mobility  in  others  is  char- 
acteristic of  the  different  forms  of  dislocation.  Immobility  may  be  increased 
by  muscular  spasm  due  to  pain  or  diminished  by  extensive  laceration  of  the 
ligaments.  The  position  assumed  by  the  limb  is  also  characteristic ;  when 
moved,  the  limb  tends  to  return  to  it  spontaneously,  and  this  tendency  is  not 
changed  by  anesthesia.      (See  Special  Dislocations.) 

Crepitus. — During  the  examination  of  a  dislocated  limb  a  grating  may  be 
perceived  as  the  head  of  the  bone  is  moved  in  its  new  position.  This  may  be 
due  to  the  rubbing  of  one  bone  against  the  other  or  against  the  border  of  a 
stretched  tendon  or  edex?  of  fascia.     At  the  moment  when  reduction  is  accom- 


300  FKACTURES   AND   DISLOCATIONS 

plished,  in  a  joint  like  the  shoulder,  a  sharp  grating  or  click  is  often  noticed. 
It  should  not  be  forgotten  that  the  crepitation  may  be  due  to  an  associated 
fracture. 

Subjective  Symptoms. — Pain. — A  sharp  pain  in  the  vicinity  of  a  joint  is 
felt  at  the  moment  of  dislocation ;  the  pain  may  continue  unabated  if  nerves  are 
stretched,  pressed  upon,  or  torn,  or  be  associated  with  numbness ;  often  it  soon 
subsides,  but  returns  or  is  increased  by  efforts  to  move  the  limb  or  by  jolting 
movements  communicated  to  the  body. 

Loss  of  Function. — Commonly  the  dislocated  limb  is  quite  powerless. 
The  symptom  is  of  no  great  diagnostic  value,  since  it  usually  accompanies  frac- 
tures and  may  follow  contusions.  Sometimes  the  patient  is  still  able  to  use  the 
limb,  and  if  reduction  is  not  affected,  motion,  restricted,  but  perfectly  efficient 
in  certain  directions,  may  be  gradually  restored. 

Differential  Diagnosis  of  Traumatic  Dislocations. — In  sprains,  the  history  of 
the  injury,  the  pain,  and  the  swelling  are  similar.  The  joint  is  often  immobile 
on  account  of  pain.  Under  anesthesia  the  immobility  disappears,  and  the  joint 
can  then  be  moved  freely.  Fractures  in  the  neighborhood  of  joints,  and  notably 
impacted  fractures,  are  at  times  not  easy  to  differentiate  from  dislocations,  if, 
when  first  seen,  much  swelling  exists.  Abnormal  mobility  and  crepitation,  of 
course,  indicate  fracture.  The  deformity  of  fracture  if  not  impacted  may  often 
be  readily  reduced,  but  returns  at  once ;  the  deformity  of  dislocation  may  be 
difficult  to  reduce,  but  once  effected,  the  deformity  does  not  return.  In  cases  of 
doubt,  examination  under  general  anesthesia  is  always  advisable.  An  X-ray 
picture  will  usually  establish  a  correct  diagnosis. 

Congenital  Dislocations. — Congenital  dislocations  are  due  to  arrest  of  devel- 
opment or  deformity  of  the  articular  extremities  or  surfaces  of  a  joint.  They 
are  far  more  common  in  the  hip  than  in  any  other  joint,  but  occasionally  occur 
in  the  elbow,  the  shoulder,  and  other  joints.  Frequently  they  are  not  noticed  in 
the  hip- joint  until  the  child  begins  to  walk.  The  signs  of  traumatism  are  of 
course  absent,  and  instead  of  fixation  or  limitation  of  motion  in  the  joint  an 
abnormal  degree  of  mobility  exists,  due  to  the  imperfect  development  of  the 
end  of  the  bone  and  to  the  relaxed  ligaments  and  joint  capsule.  The  diagnosis 
is  made  by  the  discovery  of  the  head  of  the  bone  in  an  abnormal  position, 
the  shortening  of  the  limb,  and  the  deformed  appearance  of  the  joint  itself. 
In  the  hip  the  shortening  leads  to  a  limp,  and  if  but  one  joint  is  affected  to 
scoliosis,  which  is  quite  marked,  but  can  be  overcome  temporarily  by  having 
the  child  place  the  affected  foot  upon  a  book  or  other  object  of  suitable  height. 

In  single  and  double  dislocations  there  is  marked  lordosis  in  the  erect 
posture,  which  disappears  when  the  child  is  placed  flat  upon  its  back.  In 
double  dislocation  also  the  child  has  a  peculiar  waddling  gait,  which  is  fairly 
characteristic.  An  absolute  diagnosis  is  made  by  feeling  the  trochanter,  and 
sometimes  the  head  of  the  bone  upon  the  dorsum  of  the  ilium,  the  ordinary 
form  of  dislocation.  The  articular  extremity  is  displaced  upward,  and  meas- 
ured shortening  is  well  marked.     The  bodies  of  these  patients  being  small,  very 


DISLOCATIONS  301 

perfect  X-ray  pictures  are  easily  taken,  and  demonstrate  the  condition  beyond 
the  shadow  of  a  doubt. 

Pathological  or  Spontaneous  Dislocations. — These  are  always  acquired,  are 

the  result  of  disease,  sometimes  of  the  joint  itself,  sometimes  secondary  to  other 
diseases.  They  were  divided  by  Volkmann  into  three  groups,  as :  First,  dislo- 
cations by  distention ;  second,  by  destruction ;  third,  by  deformity. 

1.  Dislocations  by  Distention. — It  was  believed  by  Volkmann,  and  has 
been  held  by  others,  that  these  dislocations  occurred  as  the  result  of  the  disten- 
tion of  the  capsule  of  the  joint  by  fluid  exudates.  The  result  of  synovites  of  an 
acute  character,  such  as  acute  articular  rheumatism,  the  metastatic  synovites 
complicating  the  acute  exanthemata,  typhoid  fever,  pyemia,  etc.,  and  gravity 
and  muscular  action,  were  regarded  as  secondary  factors  in  the  production  of 
the  dislocation.  It  was  pointed  out  by  Stimson,1  however,  that  the  marked  dis- 
tention of  the  joint  is  assumed  rather  than  demonstrated,  and  that  these  disloca- 
tions occur  in  cases  where  pain  and  muscular  spasm  are  marked,  and  when  the 
limb  has  long  been  held  in  such  a  position  that  gravity  and  muscular  action 
favor  the  occurrence  of  dislocation,  and  Stimson  believes  that  these  two  latter 
factors  are  the  true  cause  of  the  dislocation,  rather  than  the  relaxation  of  the 
joint  capsule  produced  by  overdistention.  He  considers  that  the  effusion  into 
the  joint  favors  the  occurrence  of  dislocation  merely  by  removing  the  influ- 
ence of  atmospheric  pressure  in  holding  the  joint  surfaces  together. 

The  dislocation  occurs  most  often  in  the  hip- joint  when  patients  with  a 
painful  affection  of  the  joint  have  lain  for  a  considerable  time  with  the  limb 
in  the  position  of  flexion,  adduction,  and  internal  rotation.  The  dislocation 
occurs  suddenly  upon  the  dorsum  of  the  ilium,  and  is  usually  followed  by  relief 
of  pain.  The  diagnosis  is  made  by  the  ordinary  methods  of  examination,  and 
reduction  is  effected  by  manipulation,  and  is  permanent. 

2.  Dislocations  by  Destbxtction. — In  these  the  dislocation  is  produced 
by  destruction  of  the  articular  ends  of  the  bones,  such  as  occur  in  the  course 
of  joint  tuberculosis,  in  tabetic  joints,  or  as  the  result  of  acute  suppurative 
joint  lesions  with  destruction  of  the  ligaments.  Paralysis  of  the  muscles  sur- 
rounding a  joint  may  result  in  dislocation  in  one  of  two  ways.  If  all  the 
muscles  are  paralyzed,  an  important  part  of  the  support  of  the  articulation 
is  lost,  and  the  bones,  as  sometimes  happens  in  the  shoulder-joint,  may  simply 
fall  away  from  one  another  by  gravity ;  such  a  dislocation  is  accompanied  by 
a  serous  effusion  into  the  joint.  When  only  certain  groups  of  muscles  near  a 
joint  are  paralyzed  while  other  groups  continue  to  act  unopposed,  the  latter 
may  produce  a  dislocation  by  muscular  contraction ;  such  dislocations  have  been 
noticed  (hip)  in  the  course  of  spinal  caries,  producing  pressure  upon  the  spinal 
cord  and  paralysis  of  the  adductors  of  the  thigh  or  of  the  external  rotators 
attached  to  the  trochanters.  If  the  adductors  are  paralyzed  while  the  muscles 
upon  the  outer  side  and  back  of  the  thigh  continue  to  act,  the  dislocation  will 

1  Stimson,  loc.  cit.,  p.  477. 


302  FRACTURES    AND   DISLOCATIONS 

be  upon  the  pubis.  If  the  trochanteric  muscles  are  paralyzed  while  the  adduc- 
tors act  unopposed,  the  dislocation  will  be  upon  the  dorsum  of  the  ilium. 

A  very  common  form  of  partial  dislocation  the  result  of  muscular  contrac- 
tion is  the  dislocation  backward  of  the  tibia  in  untreated  tuberculosis  of  the 
knee-joint  produced  by  the  action  of  the  hamstring  muscles.  When  one  of 
two  paired  bones  grows  faster  than  the  other,  or  the  development  of  one  of 
them  is  arrested,  and  in  a  few  cases  of  compound  fracture  of  one  of  two  paired 
bones,  .with  loss  of  substance  and  failure  of  union  of  one  of  the  bones,  a  gradual, 
complete,  or  partial  dislocation  by  muscular  action  may  occur. 

3.  Dislocations  by  Deformity. — Under  this  head  Volkmann  and  other 
authors  have  included  the  dislocations  which  occur  in  arthritis  deformans  and 
in  tabes — "  Charcot's  joint."  The  dislocation  is  produced  partly  by  atrophy 
and  absorption  of  bone  and  partly  by  the  growth  of  new  bone  forcing  the  articu- 
lar surfaces  into  an  abnormal  position.  The  dislocations  may  be  sudden  or 
gradual  in  their  occurrence,  and  complete  or  partial. 


CHAPTER    IX 

SYPHILIS  AND   LEPROSY 

SYPHILIS 

Syphilis  is  a  chronic,  contagions,  infections  disease,  produced  by  inocula- 
tion with  the  syphilitic  virus  or  contagium.  It  is  hereditary  in  the  sense  that 
it  may  be  transmitted  to  the  offspring  of  the  syphilitic  individual.  The  course 
of  the  disease  and  the  character  of  its  lesions  present  so  many  resemblances 
and  analogies  to  chronic  infectious  diseases  known  to  be  of  bacterial  origin 
that  it  has  long  been  the  belief  of  pathologists  that  syphilis  must  have  a  similar 
causation. 

Syphilis  has  long  been  studied  clinically  and  experimentally  in  the  search 
for  its  essential  cause,  and  a  large  number  of  bacterial  forms  have  from  time 
to  time  been  found  in  syphilitic  lesions.  ISTone  of  these  have  been  shown  to 
bear  a  causative  relation  to  the  disease.  In  1905,  however,  Schaudinn  and 
Hoffmann  discovered  in  the  secretions  of  syphilitic  sores  an  organism  hitherto 
undescribed,  which  they  believed  might  be  the  cause  of  syphilis,  and  their 
observations  have  since  been  confirmed  by  a  very  large  number  of  observers. 

The  organism  is  quite  regularly  found  in  the  lesions  of  early  untreated 
syphilis.  It  has  been  found  in  the  blood  of  syphilitic  patients,  and  in  some 
of  the  later  lesions  of  the  disease.  Though  the  organism  has  not  been  culti- 
vated, and  but  little  is  known  of  its  life  history,  yet  a  constantly  accumulating 
mass  of  evidence  seems  to  point  to  the  conclusion  that  the  Spirocheta  pallida 
(Spironema,  treponema  pallida)  is  the  exciting  cause  of  syphilis. 

The  Spirocheta  pallida. — The  Spirocheta  pallida  may  be  examined  alive  in 
the  secretions  of  an  open  syphilitic  lesion,  best  during  the  early  stages  of  the 
disease.  The  scrapings  from  a  syphilitic  sore  may  be  mounted  under  a  cover- 
glass  protected  from  evaporation  by  sealing  with  wax  or  paraffin.  The  best 
results  are  obtained  by  scraping  the  lesions  quite  deeply.  The  fewer  leucocytes 
in  the  exudate  the  more  spirochete  it  is  likely  to  contain   (Ewing). 

It  is  a  spiral  organism  (see  Fig.  116),  which  varies  in  length  from  4—11  /a. 
Its  diameter  varies  from  ^  ^  to  immeasurable  tenuity.  It  is  cylindrical,  and 
shows  usually  from  six  to  twelve  spirals,  though  as  many  as  twenty  have  been 
observed.  The  length  and  depth  of  the  spirals  varies  from  1-1.5  p.  The 
organism  is  motile,  and  shows  motion  of  three  kinds:  a  rotation  upon  its  long 
axis,  a  bending  upon  its  axis,  and  a  to-and-fro  movement.     In  fresh  prepara- 

303 


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304 


SYPHILIS  305 

tions  the  motions  arc  quite  active,  though  the  organism  does  not  notably  change 
ils  position.  Though  the  spirochete  may  be  observed  in  the  living  slate,  they 
are  best  seen  and  studied  after  staining.  Whether  in  secretions  or  in  the 
tissues,  they  are  found  almost  without  exception  outside  the  cells.  The  follow- 
ing description  of  the  staining  methods,  as  well  as  the  figures  showing  the 
organisms  in  secretions  and  tissues,  are  quoted  from  "  Syphilis/'  by  Edward 
L.  Keycs,  Jr. : 

Methods  or  Staining. — The  Spirocheta  pallida  approximates  the  protozoa  in 
its  resistance  to  the  usual  bacterial  stains.  The  classic  method  of  preparing  and 
staining  is  Schaudinn  and  Hoffmann's  modification  of  Giemsa,  as  follows: 

1.  Obtain  the  specimen  by  scratching  the  surface  of  the  lesion  (chancre,  mucous 
patch),  after  having  washed  it  thoroughly  clean  of  all  contamination — the  admix- 
ture of  a  trace  of  blood  does  no  harm.  Spread  the  secretion  thus  obtained  as  thin 
as  possible;  dry  without  heating;  harden  for  fifteen  minutes  in  absolute  alcohol. 

2.  Employing  the  Giemsa  stain  (made  by  Griibler,  of  Leipzig),  dilute  this  by 
adding  about  1  drop  to  1  c.c.  of  water  (to  which  1  to  10  drops  of  1 :  1,000  calcium 
carbonate  has  been  previously  added — this  is  advantageous  but  not  essential). 

3.  Immediately  spread  the  diluted  stain  on  the  specimen  and  let  it  stand  one 
hour. 

1.  "Wash  freely  in  water,  dry  without  heating,  and  mount. 

This  is  the  standard  stain.  A  quicker  method  is  that  of  Simonelli  and  Bandi x 
or  of  Goldhorn,2  sold  in  this  country  under  the  name  of  Goldhorn's  stain.  A  few 
drops  of  this  will  stain  a  specimen  (dried  without  heating)  in  two  or  three  seconds. 
The  smear  is  then  rinsed  in  water  and  dried  (cold). 

In  France  a  favorite  stain  is  the  Marino  blue;  innumerable  other  stains  have 
been  tried,  but  the  Giemsa  and  the  Goldhorn  fill  all  requirements.  With  Giemsa 
the  spirochete  appear  of  a  faint  red  color.  The  Goldhorn  stains  them  purplish, 
which  may  be  changed  to  brownish-black  by  treating  the  specimen  with  gram  or 
lugol. 

Tissue  Stain. — The  best  is  Levaditi's  modification  of  the  Eamon  y  Cajal  silver 
stain.3 

1.  Sections  are  cut  1  mm.  thick  and  hardened  in  ten  per  cent  formalin  for 
twenty-four  hours. 

2.  Wash  and  harden  in  ninety-six  per  cent  alcohol  twenty-four  hours. 

3.  Wash  a  few  minutes  in  water  until  they  sink. 

4.  Impregnate  with  silver  by  soaking  for  three  (to  five)  days  in  a  1.5  per  cent 
(to  three  per  cent)  solution  of  silver  nitrate  at  a  temperature  of  38°  C. 

5.  Wash  rapidly  in  water  and  place  for  twentv-four  (to  forty-eight)  hours  at 
the  room  temperature  in 

Acid  pyrogallic 2  gm. 

Formalin 5  c.c. 

Aq.  destill 100  c.c. 

1  Centralbl.  /.  Bad.,  Parasit.  v.  Infect.,  1905,  vol.  xl,  p.  159. 

2  Jour,  of  Exper.  Med.,  1906,  vol.  viii,  p.  451. 

3  The  so-called  old  Levaditi,  in  contradistinction  to  the  new  or  pyridin  Levaditi,  which  is 
quicker  but  not  so  accurate. 

21 


306  SYPHILIS    AND   LEPROSY 

6.  Wash,  dehydrate'  in  absolute  alcohol,  and  mount  in  paraffin. 

7.  Cut  sections  no  thicker  than  5  /a. 

8.  Stain  either  with  (a)  Gienisa,  for  a  few  minutes;  wash  in  water,  differentiate 
in  alcohol  containing  a  few  drops  of  oil  of  cloves,  clarify  in  xylol,  and  mount  in 
balsam;  or  (&)  concentrated  toluidin-blue  solution,  differentiate  in  alcohol  contain- 
ing a  few  drops  of  Unna's  ether-glycerin  mixture — xylol,  balsam. 

Diagnosis  of  Spirocheta  pallida. — The  time  and  skill  required  to  perform 
the  Levaditi  stain  successfully  suffice  to  keep  tissue  staining  apart,  to  be  employed 
only  by  the  most  competent  specialists.  Current  examinations  for  Spirocheta  pallida 
may  be  attempted  only  on  smears  stained  with  Goldhorn  or  Giemsa. 

Examination  of  such  a  smear  promptly  reveals  how  appropriate  is  the  name, 
Spirocheta  pallida;  for  so  pale  and  thin  are  these  microorganisms,  that  at  first 
one  finds  great  difficulty  in  perceiving  them.  It  has  been  generally  noted  that  the 
observer  at  first  makes  very  few  positive  finds.  But,  having  at  last  identified  the 
spirocheta  and  got  it  photographed,  as  it  were,  on  his  retina,  he  can  return  to  speci- 
mens previously  found  negative  and  discover  the  organism  in  them — perhaps  in 
great  numbers. 

Hence  the  discovery  of  Spirocheta  pallida  requires  not  only  familiarity  with 
ordinary  laboratory  and  microscopic  technic,  but  also  a  relatively  long  and  tedious 
special  training.  Unhappily,  it  is  to  be  foreseen  that,  as  spirocheta  diagnosis 
assumes  greater  and  greater  prominence  in  the  diagnosis  of  syphilis,  the  tribe  of 
near  pathologists  will  feel  fully  competent  to  pass  upon  this — the  most  delicate 
point  in  the  diagnosis  of  the  most  important  infectious  disease  that  afflicts  man- 
kind; to  the  cocksure  diagnosis  of  the  hasty  practitioner  will  be  added  the  scientific 
diagnosis  of  incompetence.  Eor  spiral  organisms  abound  both  upon  the  skin  and 
upon  the  mucous  membranes.  In  the  mouth  are  found  Spirocheta  denticula,  Spi- 
rocheta buccalis,  Spirocheta  Vincenti;  in  the  bowel,  Spirocheta  dysenteric;  on  the 
skin,  Spirocheta  refringens  and  various  saprophytic  varieties. 

The  accompanying  photographs  (Fig.  116)  show,  however,  the  characteristic 
features  distinguishing  Spirocheta  pallida  from  every  other  variety  of  spirocheta. 
These  are: 

1.  Extreme  tenuity  and  faint  staining. 

2.  Multiple  small,  abrupt  spirals. 

All  of  the  other  familiar  spirochetal  are  much  thicker  (most  of  them  are  longer), 
stain  readily  with  the  common  dyes,  and  exhibit  long,  gentle  undulations  in  bril- 
liant contrast  to  the  sharp,  short,  almost  angular  spirals  of  Spirocheta  pallida. 

This  is  not  to  say  that  every  Spirocheta  pallida  seen  can  be  identified  as  such, 
or  that  every  specimen  containing  Spirocheta  pallida  can  be  diagnosed  even  by  the 
most  skilled  observer.  Indeed,  quite  the  converse  is  true.  Even  Neisser  confesses 
to  a  doubt  about  certain  of  his  cases.  But  a  characteristic  Spirocheta  pallida  is  as 
typical  to  a  skilled  eye  as  is  a  characteristic  gonococcus,  for  example,  and  affords 
quite  the  same  diagnostic  certainty. 

But  before  a  negative  report  can  be  given,  repeated,  prolonged,  systematic,  and 
skilled  examinations  must  be  made. 

Where  may  Spirocheta  pallida  be  Found? — The  earlier  observers  were  able 
to  discover  Spirocheta  pallida  only  in  the  earliest  (and  most  infectious)  lesions  of 
the  disease.  The  following  condensed  list  shows  the  results  obtained  by  those 
reporting  the  greatest  number  of  cases: 


SYPHILIS  307 

Oppenheim  and  Sachs  examined  118  cases,  with  39  positive  results. 

Mulzer,  22  cases,  2  positive;  56  controls,  all  negative. 

Nicolas,  Favre,  and  Andre,  42  cases,  13  positive. 

Kraus  and  Prautschoff,  37  chancres,  32  positive:  25  secondaries,  18  positive. 

Siebert,  18  chancres,  13  positive;  46  secondaries,  39  positive;  46  control  exami- 
nations negative;  6  lymph  node  serum  negative;  7  gummata  negative;  cerebrospinal 
fluid,  blood  and  semen  negative. 

Sobernheim  and  Tomasczewski,  50  cases,  all  positive;  28  controls,  all  negative. 

Scholtz,  37  cases,  all  positive. 

Schaudinn  (second  report),  70  cases,  all  positive. 

Eoscher,  32  chancres,  31  positive;  58  moist  papules,  55  positive;  40  dry  papules 
and  pustules,  34  positive;  29  mouth  lesions,  28  positive;  38  lymph  node  serum,  30 
positive ;  24  controls  negative. 

Sufficiently  exjjert  and  conscientious  investigation,  therefore,  reveals  Spirocheta 
pallida  in  fully  three  fourths  of  the  smears  taken  from  chancres,  moist  papules, 
and  mouth  lesions. 

It  was  to  be  hoped  that  aspiration  of  the  lymph  nodes  adjacent  to  the  chancre 
might  prove  a  simple  means  of  obtaining  uncontaminated  smears  of  Spirocheta 
pallida;  but,  unfortunately,  the  microorganism  is  rare  in  the  center  of  nodes,  being 
chiefly  confined  to  the  region  of  the  periphery,  so  that  there  is  a  distinctly  less 
probability  of  finding  them  there  than  in  the  chancre  itself. 

Though  the  later  secondary  lesions  contain  fewer  spirochetal,  these  have  been 
found  as  late  as  nine  years  after  chancre  by  Sobernheim  and  Tomasczewski. 

They  have  been  found  in  the  pus  from  a  nonsyphilitic  abscess  occurring  during 
the  acute  stage  of  the  disease  (Fliigel),  in  the  serum  of  blisters  raised  by  can- 
tharides  (Levaditi  and  Petresco),  in  albuminous  urine  (Dreyer  and  Toepel),  in 
the  blood — after  many  failures,  and  only  during  the  first  few  months  and  before 
the  beginning  of  mercurial  treatment  (Noggerath  and  Stahelin,  Schaudinn,  Rich- 
ards and  Hunt  et  ah). 

Most  interesting  of  all  has  been  the  search  for  spirocheta?  in  tertiary  lesions, 
which,  for  a  long  time,  was  fruitless,  but  was  finally  crowned  with  success.  Tomas- 
czewski, who  has  found  them  in  five  out  of  ten  gummata  examined,  states  that 
eight  to  ten  hours  must  sometimes  be  spent  in  examining  smears  before  finding  a 
typical  spirocheta. 

The  moist  lesions  of  early  hereditary  syphilis  swarm  with  spirochetae,  and  they 
have  been  found  (either  in  smears  or  in  sections)  in  practically  all  the  organs  of 
stillborn  syphilitic  infants;  viz.,  liver,  lung,  spleen,  kidney,  suprarenal  muscle, 
heart,  stomach,  intestine,  mesenteric  glands,  gall-bladder  and  ducts,  ovary,  uterus, 
prostate,  testis,  urinary  bladder,  thymus,  tonsil,  bone,  joint,  etc.  They  are  usually 
most  numerous  in  the  liver,  lungs,  and  skin.  They  have  been  found  in  both  fetal 
and  maternal  placenta,  and  once  in  the  inguinal  glands  of  the  apparently  healthy 
mother  of  a  syphilitic  child  (Buschke  and  Fischer)  !  Curiously  enough,  masses  of 
spirochetal  are  sometimes  found  in  and  about  the  capillaries  where  no  tissue  change 
has  taken  place. 

They  have  not  been  found  in  the  cerebrospinal  fluid,  though  they  doubtless  will 
be,  for  positive  inoculations  have  been  obtained  upon  monkeys  with  this  fluid 
(Hoffmann). 

The  examination  of  normal  secretions — except  the  semen — is  always  negative, 


308  SYPHILIS   AND   LEPROSY 

except  in  severe  congenital  syphilis.  Whether  the  exception  in  the  case  of  semen 
is  due  to  syphilitic  lesions  in  the  seminal  canals  it  is  impossible  as  yet  to  say. 

Distribution  and  Fate. — Though  spirochete  have  been  kept  alive  for  a  few 
days  on  artificial  media,  none  of  the  attempts  at  artificial  cultivation  have  thus 
far  been  successful.1  Hence  we  are  not  in  a  position  to  affirm  with  absolute  cer- 
tainty that  the  spirocheta  is  self-sufficient,  self-multiplying,  like  the  known  bacteria, 
and  not  a  mere  developmental  form  of  some  unknown  organism  (possibly  the  cytor- 
rhictes).  Moreover,  the  multiplication,  distribution,  and  fate  of  the  spirocheta  in 
the  body  of  a  syphilitic  patient  have  not  been  worked  out  in  detail.  But  the  follow- 
ing facts  we  know : 

Spirochete  are  found  most  frequently  in  the  earliest  and  most  infectious  lesions 
of  syphilis.  Whether  in  the  chancre  and  early  secondary  lesions  of  acquired  syphilis 
or  in  the  organs  in  inherited  syphilis,  they  abound  in  the  walls  of  the  blood-vessels 
and  in  the  perivascular  tissues.  They  are  relatively  rare  in  the  lymph  vessels,  sur- 
prisingly few  in  the  nodes,  and  when  found  in  the  nodes  are  usually  in  or  about 
the  blood  capillaries  at  their  circumference  (Hoffmann  and  Beer).  They  have 
been  found  in  great  numbers  among  the  epithelia  of  the  chancre  or  the  moist 
papule.  A  few  observers  believe  they  have  seen  evidence  that  the  spirochete  are 
destroyed  by  phagocytosis.  In  tertiary  lesions  (gummata)  they  have  been  found 
only  in  the  active,  advancing  edge  of  the  lesion,  never  in  its  necrotic  center  or 
in  its  secretion. 

It  seems  probable,  therefore,  that  the  spirochete  are  distributed  by  the  lymph 
rather  than  by  the  blood  current,  directly  excite  the  perivascular  inflammation  char- 
acteristic of  all  syphilitic  lesions,  and  are  destroyed  by  phagocytosis. 

Although  a  few  observers  have  denied  that  the  administration  of  mercury  has 
any  effect  upon  the  spirocheta,  it  is  the  consensus  of  opinion  that,  as  soon  as  mer- 
cury is  administered,  the  spirochete  rapidly  disappear  and  soon  are  undiscoverable, 
and  this  disappearance  seems  to  be  especially  rapid  under  inunction  and  hypo- 
dermic medication. 

Symptoms  of  Syphilis. — Following  inoculation  with  the  syphilitic  virus  there 
occurs,  after  a  period  of  incubation  which  is  rarely  less  than  two  weeks  and 
may  be  six  weeks  or  more,  a  cellular  infiltration  at  the  point  where  the  inocu- 
lation took  place  with  the  production  of  a  small  nodule  usually  characterized 
by  hardness  or  induration.  This  is  the  so-called  initial  lesion  of  syphilis,  the 
hard  chancre,  Tlunterian  chancre.  After  a  brief  interval  the  lymphatic  glands 
of  the  region  become  enlarged  and  hard.  Subsequently  the  lymphatic  glands 
of  other  regions  undergo  similar  enlargements,  there  follows  some  disturbance 
of  the  general  health,  accompanied  in  many  cases  by  slight  fever,  and  the 
outbreak  upon  the  general  integument  and  mucous  membranes  of  a  series  of 
eruptions — roseola,  erythema,  papules,  pustules.  These  eruptions  are  at  first 
general  and  superficial ;  at  a  later  period  they  are  commonly  grouped,  and  of 
a  less  superficial  character.  The  disease  may  end  here  and  the  patient  have 
no  further  symptoms  during  his  lifetime,  or  at  once,   or  after  any  possible 

1  Quite  recently  Spirocheta  refringens  has  been  cultivated  by  Levaditi;  Spirocheta  obermeieri 
by  Novy;  perhaps  Spirocheta  pallida  will  be  the  next. 


SYPHILIS  309 

interval,  subacute  and  chronic  inflammations  may  occur  in  any  of  the  tissues 
of  the  body.  Very  often  these  later  lesions  of  the  disease  are  in  the  form  of 
small  or  large  nodular  infiltrations,  which  tend  to  undergo  a  peculiar  form 
of  degeneration;  they  are  known  as  gummata,  and  are  especially  prone  to 
involve  the  connective  tissues. 

A  further  series  of  lesions  occur  as  the  result  of  syphilis ;  they  are  notably, 
sclerotic  changes  in  the  central  nervous  system  and  changes  in  the  walls  of  the 
arteries,  notably  of  the  smaller  arteries  of  the  brain. 

During  the  period  when  active  symptoms  are  present,  always  for  several 
years,  and  in  most  instances  during  his  entire  lifetime,  the  individual  enjoys 
immunity  from  infection  with  the  virus  of  syphilis.  There  are  two  further 
kinds  of  immunity  from  syphilis  which  may  be  important  from  a  diagnostic 
point  of  view :  First,  the  wife  of  a  syphilitic  man  may  give  birth  to  a  syphilitic 
child,  show  no  symptoms  of  the  disease  herself,  and  yet  be  immune  to  syphilis. 
Second,  syphilitic  parents  may  give  birth  to  healthy  children,  who  never  show 
any  symptoms  of  the  disease,  but  are  immune.  The  immunity  of  an  indi- 
vidual inoculated  with  syphilis  begins  at  or  before  the  time  of  the  appearance 
of  the  initial  lesion. 

It  is  customary,  in  describing  the  disease,  to  divide  it  into  a  number  of 
different  stages  or  periods,  but  it  is  to  be  remembered  that  these  stages  are 
for  the  most  part  artificial — that  is  to  say,  the  process  of  the  invasion  of  the 
organism  is  continuous  from  the  start  and  the  successive  groups  of  lesions 
occur  simply  as  the  result  of  the  successive  involvement  of  various  kinds  of 
structures — and  that  in  many  cases  the  several  types  of  lesion,  by  the  characters 
of  which  and  the  date  of  their  appearance  the  disease  is  divided  into  a  number 
of  stages,  may  follow  one  another  after  longer  or  shorter  intervals,  or  in  rapid 
succession,  or  they  may  be  coexistent.  The  general  symptoms  of  intoxication 
may  be  immediately  followed  by  lesions  ordinarily  occurring  late  in  the  dis- 
ease, or  rarely  the  initial  lesion,  or  what  appears  to  be  an  initial  lesion,  may 
be  followed  by  no  further  symptoms  whatever. 

In  a  certain  large  proportion  of  cases,  however,  the  course  of  the  disease 
is  marked  by  more  or  less  definite  stages  or  periods :  First,  a  period  of  incuba- 
tion, from  the  time  of  the  inoculation  until  the  appearance  of  the  initial  lesion, 
from  ten  days  to  six  weeks ;  on  the  average  about  twenty-one  days.  Second, 
the  primary  period  of  the  disease,  consisting  of  the  initial  lesion  and  the  asso- 
ciated adenitis  of  the  neighboring  lymph  glands.  The  duration  of  the  exist- 
ence of  the  initial  lesion  is  very  variable,  and  will  be  discussed  later  on.  A 
second  period  of  so-called  incubation  occurs,  during  which  the  virus  is  slowly 
being  disseminated  throughout  the  entire  organism ;  it  ends  with  the  appear- 
ance of  the  secondary  symptoms.  Its  duration  is  variable,  but  is  in  general 
from  eight  to  nine  weeks  from  the  time  of  inoculation,  or  six  weeks  from  the 
appearance  of  the  initial  lesion.  Tt  may  be  prolonged  several  months.  In 
one  experimental  inoculation  it  is  said  to  have  been  prolonged  to  one  hundred 
and  fifty-nine  days. 


310  SYPHILIS    AXD   LEPEOSY 

The  Period  of  Secondary  Symptoms,  Secondary  Syphilis. — The  symptoms  dur- 
ing this  period  consist  chiefly  of  lesions  of  the  skin  and  mucous  membrane, 
though  many  other  structures  may  be  involved.  They  include  macules,  papules, 
pustules,  and  affections  of  the  appendages  of  the  skin,  the  hair  and  nails,  the 
eye,  and  the  equivalent  of  the  various  skin  lesions  as  they  occur  upon  the  mu- 
cous membranes.  This  period  is  of  variable  duration — from  one  to  three  years. 
An  intermediate  period  following  this  is  described,  during  which  either  no 
symptoms  at  all  are  present  or  the  symptoms  are  of  an  irregular  character, 
localized  rather  than  general.  The  patient  may  or  may  not  be  contagious,  and 
may  or  may  not  infect  his  offspring.  The  duration  of  this  period  is  variable ; 
it  may  last  from  one  to  several  years,  and  end  in  recovery  without  further 
symptoms,  or  be  followed  after  an  indefinite  interval  by  the  so-called  tertiary 
lesions  of  the  disease.  These  consist  of  more  deeply  seated,  sometimes  de- 
structive, lesions  of  the  skin  and  mucous  membranes  and  subcutaneous  con- 
nective tissues,  of  inflammations  of  the  bones,  of  the  internal  organs,  of  inflam- 
mations of  the  arteries,  the  formation  of  gummata.  The  duration  of  the  period 
is  indefinite. 

Infection  with  Syphilis. — Infection  may  occur  from  the  inoculation  from 
the  secretion  of  the  initial  lesion  or  chancre,  from  the  secretion  of  any  open 
lesion  during  the  secondary  or  active  period  of  the  disease,  most  commonly 
from  the  secretion  of  a  chancre  or  of  a  papule  situated  upon  a  mucous  mem- 
brane— the  so-called  mucous  patch — or  from  a  moist  papule  situated  at  a  muco- 
cutaneous junction,  or  from  the  blood  of  an  individual  during  the  active  or 
contagious  stage  of  the  disease.  The  normal  secretions  of  the  body — the  tears, 
the  saliva — are  not  contagious ;  the  semen  may  infect  the  ovum.  It  is  be- 
lieved that  the  blood  is  much  less  contagious  than  the  secretion  from  an 
open  syphilitic  sore.  The  late  or  tertiary  lesions  of  syphilis  may  not  be  con- 
tagious. Inoculation  is  effected  through  a  solution  of  continuity  of  the  epi- 
thelial covering  of  the  skin  or  mucous  membrane.  Such  a  lesion  may  be 
gross  or  microscopic. 

Modes  of  Contagion. — Inoculation  may  be  direct  or  mediate,  from  the  direct 
implantation  of  the  virus  from  the  body  of  one  individual  to  that  of  another, 
or  mediate  through  the  medium  of  infected  articles — surgical  or  dental  instru- 
ments, pipes,  drinking  vessels,  razors,  towels,  toothbrushes,  etc.  Though  the 
infection  occurs  in  the  largest  proportion  of  cases  during  sexual  intercourse, 
nonvenereal  syphilis  is  very  common  indeed.  Surgeons,  obstetricians,  hospital 
nurses,  wet-nurses,  and  others  who  are  frequently  brought  into  contact  with 
the  disease  in  innocent  ways,  not  rarely  acquire  syphilis,  and  purely  accidental 
infections  are  sufficiently  common. 

The  Initial  Lesion  of  Syphilis,  Chancre  (Hard  Chancre — Infecting  Chancre 
— Hunterian  Chancre — Ulcus  durum — Hard  Sore). — Following  inoculation, 
no  changes  are  observed  at  the  point  where  the  virus  was  introduced  for  a 
period  of  from  ten  to  forty  days — twenty-one  days  on  the  average.  The  wound 
or  abrasion,  if  large  enough  to  be  noticed,  heals  in  the  ordinary  way.     At  the 


SYPHILIS 


311 


end  of  the  period  of  incubation  there  appears  at  the  point  of  infection  a  small 
papule  or  patch  upon  the  surface,  or  a  fissure  or  excoriation,  usually  single. 
There  may  be  no  raw  surface  at  any  time,  but  simply  a  little  desquamation 
of  superficial  epithelium.  Moderate  red- 
ness of  the  surface  is  present — usually 
dull  red,  coppery  red,  or  purplish  red — 
but  scarcely  any  pain  or  sensitiveness. 
Gradually  there  is  developed  an  infiltra- 
tion of  the  thickness  of  the  skin  or  mu- 
cous membrane,  which  increases  in  depth, 
and  superficial  area ;  sometimes  when  first 
noticed,  usually  within  a  week  from  its 
appearance,  there  is  developed  the  char- 
acteristic induration.  This  may  be  nodu- 
lar and  involve  the  entire  thickness  of  the 
skin,  or  quite  superficial. 

The  nodular  form  is  of  peculiar  car- 
tilaginous hardness,  quite  insensitive,  mov- 
able upon  the  deeper  structures  when  situ- 
ated in  loose  skin.  When  pinched  its 
surface  becomes  blanched,  quite  white,  and 
strongly  suggests  a  little  button  of  cartil- 
age.     In   the   more   superficial   form   the 

induration  is  best  appreciated  by  lifting  the  area  of  infiltration  between  the 
finger  and  thumb  and  making  lateral  pressure.  The  part  feels  as  though  a  bit 
of  parchment  or  stiff  paper  were  being  grasped.  An  annular  form  of  indura- 
tion may  exist — a  ring  of  hard  infiltration  surrounding  an  area  where  the 
normal  softness  and  elasticity  of  the  tissues  is  preserved. 

The  epithelial  covering  may  remain  unbroken  throughout  the  existence  of 
the  chancre  and  be  merely  thinned  over  its  center,  or  more  commonly  a  super- 
ficial ulcer  forms,  usually  rounded  or  oval  in  shape.  The  base  of  the  ulcer  is 
very  slightly  depressed,  smooth,  and  of  a  color  which  has  been  likened  to  raw 
ham,  or  covered  with  a  superficial  grayish-white,  adherent,  soft  scab  or  layer 
of  false  membrane.  The  discharge  is  small  or  large  in  amount,  and  watery, 
often  lemon-yellow  in  color.  The  raw  surface  bleeds  readily.  Sections  of 
chancre  under  the  microscope  show  round-celled  infiltration  of  lymph  spaces 
and  thickening  of  the  coats  of  the  small  blood-vessels,  arteries,  and  veins. 
Epithelioid  and  giant  cells  are  present  in  moderate  numbers. 

The  induration  is  of  very  variable  size.  It  may  be  no  larger  than  the  head 
of  a  match  or  cover  a  considerable  extent  of  surface  and  be  quite  massive — 
two  thirds  of  the  circumference  of  the  prepuce,  for  example.  Chancres  vary 
in  appearance  and  physical  characters  according  to  their  seat  and  according 
to  whether  they  are  irritated  chemically,  mechanically,  or  infected  with  pus 
microbes.     A  number  of  forms  are  commonlv  described.     The  ulcus  elevatum 


Fig.  117. — Ulcerated  Ixitial  Lesion*  of 
Syphilis.  The  hard  chancre — Hunter- 
ian  chancre. 


312 


SYPHILIS   AND   LEPROSY 


Fig.  118. — Chancre  of  the  Chin  believed  by  the 
Patient  to  have  been  acquired  by  Shaving 
with  a  Razor  which  had  been  used  by  a 
Syphilitic  Friend.     (Author's  collection.) 


and  disappear  after  a  variable  peri- 
od ;  usually  the  sore  is  healed  in 
six  weeks.  The  induration  may 
persist  for  months,  or  even  for 
years,  and  the  seat  of  the  chancre 
may  again  become  indurated  later 
in  the  disease.  There  may  be  no 
scar,  or  a  slight  or  marked  scar, 
after  the  chancre  disappears,  de- 
pending upon  the  presence  or  ab- 
sence of  erosion  or  ulceration,  and 
its  depth.  An  infected  chancre  be- 
neath a  tight  prepuce  may  destroy 
the  greater  portion  of  the  glans  pe- 
nis. Chancre  of  the  meatus  urina- 
rius,  glans  penis,  sulcus  coronarius, 
inner  layer  of  the  prepuce,  usually 
show  marked  induration.  Upon 
the  general  integument  and  skin  of 
the  body  of  the  penis  the  indura- 
tion is  less  marked. 


is  the  ordinary  eroded  or  ulcerated 
hard  nodule  in  which  cell  infiltra- 
tion elevates  the  sore  above  the  level 
of  the  skin.  The  so-called  silvery 
spot  occurs  upon  the  glans  penis  and 
meatus ;  it  is  at  first  minute,  of  a 
silvery  white  color ;  later  it  enlarges 
and  assumes  the  ordinary  character 
of  chancre.  The  dry  scaling  papule 
is  the  form  already  indicated  in 
which  erosion  does  not  take  place ; 
the  surface  remains  covered  with 
epithelium,  and  is  of  a  dull-red  or 
coppery  color. 

ECTHYMATOTTS      CHANCRE. 111 

certain  chancres  necrosis  of  the  in- 
durated area  may  occur,  superficial 
or  total,  and  separate  as  a  slough, 
brown  or  black  in  color.  Pyogenic 
infection  may  cause  the  signs  of 
acute  inflammation  and  a  purulent 
discharge  from  the  raw  surface. 
Treated  or  untreated,  chancres  heal 


Fig.  119. — Chancre  of  the  Lower  Lip. 
(Author's  collection.) 


SYPHILIS 


313 


Chancre  of  the  Vulva. — In  women,  chancres  of  the  labia  majora  may 
be  accompanied  by  general  edema  and  thickening  of  the  labium,  and  the  specific 
induration  at  the  site  of  inoculation  may  be  present  or  absent.  Chancres  of 
the  labia  minora  and  fourchette  are  not  usually  markedly  indurated. 

Extba-genital  Chancre. — Upon  the  lip  the  chancre  appears  as  an  ele- 
vated, juicy-looking,  raw,  rounded  or  oval  nicer,  with  a  granular  surface, 
usually  covered  by  a  yellowish-white  or  sulphur-yellow  false  membrane  of 
partly  dried  discharge.  The  lip  may  be  markedly  swollen.  The  induration 
is  present,  but  is  not  of  the  car- 
tilaginous hardness  noted  in  chan- 
cres of  the  peuis.  Upon  the  mu- 
cous membrane  of  the  mouth  the 
chancre  appears  as  a  superficial 
ulcer,  with  reddened  edges  and  a 
base  covered  with  whitish  false 
membrane. 

Multiplicity  of  Chancre. 
— According  to  Fournier,  in  three 
cases  out  of  four  chancres  are 
single.  They  may  be  multiple. 
I  have  seen  a  chancre  upon  the 
penis  and  upon  the  lip  of  the 
same  individual ;  the  two  sores 
appeared  simultaneously.  Chan- 
cres acquired  during  sexual  con- 
tact are  usually  situated  upon 
the  genitals.  They  may  occur 
upon  the  lips,  or  within  the 
mouth  from  kissing,  or  upon  the 
nipple,  eyelid,  or  some  part  of 
the  face  from  direct  contact.  The 
margin  of  the  anus,  the  rectum, 
the  tonsil,  the  palatine  arch,  and 
other  situations  may  be  infected 
through  unnatural  practices  be- 
tween persons  of  the  same  or  of 


Fig.  120. — Chancre  of  the  Finger.  The  white  spot 
upon  the  ulcerated  surface  represents  powdered  cal- 
omel which  had  not  been  entirely  removed  when  the 
author  took  the  photograph.  In  this  case  the  chan- 
cre had  existed  for  eight  weeks  and  the  general  erup- 
tion of  a  papular  character  had  appeared  upon  the 
arms,  chest,  and  abdomen.  (The  author  was  enabled 
to  take  the  photograph  at  Bellevue  Hospital  through 
the  kindness  of  Dr.  J.  C.  Ayer.) 


the  opposite  sex.  I  saw  a  young  man  who  acquired  a  chancre  of  the  finger 
from  amorous  digital  palpation  of  the  vulva  of  a  prostitute.  The  ways  in 
which  extra-genital  chancres  may  be  innocently  acquired  are,  of  course,  in- 
numerable. I  have  recently  seen  two  cases  of  chancre  of  the  chin  from 
inoculation  during  shaving.  A  reference  to  the  characters  of  extra-genital 
chancres  will  be  made  under  Regional  Diagnosis. 

Development  of  Enlarged  Lymph  Nodes. — During  the  ten  or  twelve  days  fol- 
lowing the  appearance  of  the  initial  lesion  the  anatomically  associated  lymphatic 


314  SYPHILIS    AND    LEPROSY 

glands  become  successively  enlarged.  In  chancres  of  the  penis  the  lymphatics 
of  that  organ  are  sometimes  traceable  as  an  indurated  cord  leading  in  the 
direction  of  the  groin.  A  single  gland  is  first  noticeable  as  a  rounded,  painless, 
insensitive  nodule  in  the  subcutaneous  tissues;  the  enlargement  of  the  rest  of 
the  chain  gradually  follows,  and  the  glands  of  the  opposite  side  usually  par- 
ticipate. With  chancre  in  the  middle  line  or  near  the  frenum,  both  groins 
may  be  simultaneously  infected.  Chancres  of  the  rectum  and  anus  are  also 
followed  by  glandular  enlargements  of  the  inguinal  glands.  The  individual 
glands  are  seldom  very  large;  they  are  movable,  not  adherent  to  one  another 
nor  to  the  skin;  they  do  not  suppurate,  unless  in  the  presence  of  mixed  infec- 
tion. Chancre  of  the  lip  and  chin  or  mucous  membrane  of  the  mouth  or 
tongue  is  followed  by  enlargement  of  the  submaxillary  or  submental  glands, 
or- both;  of  the  fingers — epitrochlear  and  axillary  glands;  of  the  breast  and 
arm — axillary  glands;  of  the  eyelid — the  preauricular  glands.  The  swelling 
and  induration  of  the  glands  following  chancres  of  the  face  is  usually  very 
marked. 

Development  of  Constitutional  Symptoms. — From  forty  to  sixty  days  after 
the  appearance  of  the  chancre,  wherever  situated,  a  gradual  enlargement  of  the 
lymph  nodes  throughout  the  body  takes  place.  The  postcervical  chain  is  usually 
palpable,  and  its  enlargement  is  generally  regarded  as  of  diagnostic  value; 
these  glands  are  less  often  enlarged  from  causes  other  than  syphilis  than  the 
submaxillary  and  anterior  cervical  chains. 

Differential  Diagnosis  from  Chancroid  (Chancroid:  Soft  Chancre,  Ulcus 
molle). — Chancroid  is  an  acute  contagious  ulcerative  inflammatory  process, 
occurring  almost  exclusively  upon  the  genitalia  of  men  and  women,  occasion- 
ally in  other  situations :  in  the  rectum,  on  the  general  integument  from  direct 
or  mediate  contagion,  and  upon  the  fingers  of  surgeons  and  obstetricians  in 
rare  instances.  Ducray  and  Unna  have  described  a  small  oval,  rod-shaped 
bacillus  constantly  present  in  the  discharge  and  in  sections  of  the  base  of  the 
ulcer.  Culture  and  inoculation  experiments  have  not  as  yet  proved  successful. 
It  is  probable  that  many  venereal  sores  of  this  variety  are  caused  by  ordinary 
pyogenic  microbes  received  upon  a  favorable  soil.  The  main  importance  of 
chancroid  from  a  diagnostic  point  of  view  relates  to  a  clinical  differentiation 
between  it  and  the  initial  lesion  of  syphilis.  In  certain  instances  both  kinds  of 
infection  are  simultaneously  ingrafted  upon  a  single  point,  and  this,  for  a 
time,  may  lead  to  confusion  in  the  diagnosis. 

Characters  or  Chancroid. — The  characters  of  chancroid  are  as  follows : 
The  period  of  incubation  is  short — often  only  a  few  hours,  seldom  more  than 
two  or  three  days.  There  then  appear  at  the  seat  of  inoculation  one  or  more 
small  red,  tender,  painful,  or  itching  papules,  which  rapidly  break  down  in 
the  center  and  form  an  ulcer  with  irregular  worm-eaten  or  punched-out,  under- 
mined, inflamed  edges,  a  yellow,  sloughy  base,  and  an  abundant  purulent  dis- 
charge. The  ulcer  is  painful  and  sensitive,  tends  to  increase  in  size  and  depth, 
may  take  on  a  rapidly  progressive  sloughing  or  gangrenous  or  so-called  phag- 


SYPHILIS  315 

edenic  character;  sometimes  destroys  the  tissues  quite  widely.  New  sores 
may  be  produced  by  autoinoculation.  Chancroid  is  usually  accompanied  by 
painful  acute  inflammatory  enlargement  of  the  lymph  glands  of  the  groin.  The 
gland  or  glands  are  tender  and  painful.  Moderate  septic  fever  is  not  uncom- 
mon, and  the  glands  frequently  undergo  suppuration  and  form  a  considerable 
tumor  in  the  groin,  which  infects  and  finally  perforates  the  skin  and  dis- 
charges pus. 

The  Chancroidal  Bubo. — Numerous  glands  are  often  infected,  and  the 
walls  of  the  abscess  and  the  skin  overlying  it  undergo,  under  favorable  condi- 
tions, the  same  progressive  ulcerative  destruction  which  characterized  the 
original  sore.  Such  a  process  may  extend  indefinitely,  involve  both  groins, 
the  scrotum,  perineum,  anus,  rectum,  etc.  In  alcoholic,  underfed,  and  neglected 
cases  I  have  seen  fatal  septicemia  follow  a  chancroidal  bubo  in  more  than  one 
instance. 

Differences  from  Chancre. — The  main  points  of  difference  between 
chancre  and  chancroid  are  as  follows :  Chancroid  has  a  very  short  period  of 
incubation  or  none  at  all ;  chancre  a  period  of  incubation  rarely  less  than  two 
weeks,  average  twenty-one  days.  Chancroid  is  an  acute  inflammatory  process 
from  the  start,  characterized  by  progressive  ulceration;  chancre  is  essentially 
a  specific  hyperplasia ;  the  signs  of  acute  inflammation  are  absent.  Destruction 
of  tissue,  if  it  occurs  at  all,  is  very  slight,  unless  caused  by  mixed  infection  or 
unusual  local  or  general  conditions — confinement  of  discharges  beneath  a  tight 
prepuce,  mechanical  or  chemical  irritation,  etc.  The  discharge  from  a  chancre 
is  watery  and  thin ;  that  from  a  chancroid  is  distinctly  purulent.  The  indura- 
tion of  typical  chancre  is  of  cartilaginous  hardness  and  sharply  circumscribed ; 
chancroids  show  either  no  induration  or,  if  present,  the  hardness  shades  off 
into  the  surrounding  tissues,  and  is  rarely,  if  ever,  of  a  cartilaginous  quality. 
The  adenitis  of  chancre  is  discrete,  painless,  not  followed  by  suppuration ;  the 
adenitis  of  chancroid  follows  the  course  of  ordinary  pyogenic  infection  of 
lymph  nodes.  Periadenitis  and  matting  together  of  the  tissues  forms  a  large 
inflammatory  mass.  Suppuration  does  not  occur  in  the  adenitis  of  a  purely 
syphilitic  infection ;  the  adenitis  of  chancroid  quite  commonly  ends  in  suppura- 
tion. Lastly,  chancre  is  followed  in  most  cases  by  general  adenitis  and  char- 
acteristic eruptions  upon  the  skin  and  mucous  membranes ;  chancroid  is  not. 
In  the  cases  of  mixed  infection,  chancroid  follows  immediately  after  coitus, 
and  either  heals  or  continues  as  a  chancroidal  ulcer.  After  the  period  of 
incubation  of  syphilis  has  passed,  the  site  of  the  healed  or  unhealed  chancroid 
becomes  indurated  and  the  individual  goes  on  to  develop  constitutional  syphilis. 

Differential  Diagnosis  from  Herpes  of  the  Genitals. — Herpes  of  the  prepuce, 
of  the  glans  penis  or  meatus  urinarius,  and  of  the  muco-cutaneous  junctions 
upon  the  vulva  of  the  female,  is  an  exceedingly  common  disease.  The  lesion 
consists  of  one  or  more  small  vesicles  situated  upon  a  slightly  inflamed  and 
reddened  base.  Subjective  sensations  of  burning  and  itching  precede  and 
accompany  the  formation  of  the  vesicles.     The  lesions  are  frequently  multiple. 


316  SYPHILIS   AND   LEPROSY 

Herpes  occurs  quite  independently  of  sexual  contact,  although  the  mechanical 
irritation  of  coitus  sometimes  causes  an  attack.  The  disease  seems  often  to  de- 
pend upon  digestive  and  neurotic  disturbances.  One  attack  is  often  followed  by 
others  at  irregular  intervals,  and  in  some  individuals  such  attacks  may  occur 
every  now  and  then,  whether  they  have  coitus  or  not.  The  appearance  of 
vesicles  is  preceded  in  most  instances  by  subjective  sensations  of  itching  and 
burning  for  several  hours  or  a  day. 

Upon  inspection  one  or  more  small  patches  of  slightly  reddened  skin  may 
be  observed.  If  a  magnifying  glass  is  used,  it  is  sometimes  possible  at  this 
time  to  see  a  group  of  six,  eight,  or  more  minute  vesicles  upon  the  red  area ; 
the  whole  patch  may  be  the  size  of  a  match  head,  or  rarely  as  much  as  a  quarter 
of  an  inch  in  diameter.  After  a  day  the  vesicles  coalesce,  and  form  a  delicate 
pellicle  containing  a  drop  of  serum  and  situated  upon  an  inflamed  and  red 
base.  Several  such  lesions  may  form  simultaneously  or  successively.  Usually 
the  vesicle  is  ruptured  mechanically  in  a  few  hours,  leaving  a  superficial  red, 
moist,  excoriated  surface,  from  which  a  slight  serous  discharge  escapes.  The 
base  of  the  excoriation  shows  no  induration  and  the  inflammatory  infiltration 
is  entirely  superficial.  When  let  alone,  and  not  infected  or  irritated  mechan- 
ically or  chemically,  the  surface  dries  and  heals  in  from  three  days  to  a  week, 
leaving  behind  a  small  red,  superficial  spot,  which  disappears  in  a  few  days 
more.  When  infected  or  irritated  mechanically  or  chemically,  the  appearance 
of  the  lesion  may  be  entirely  changed  and  confusion  in  diagnosis  may  easily 
arise.     In  these  cases  time  will  render  the  diagnosis  clear. 

Diagnosis  of  Syphilis  in  the  Early  Stages  of  the  Disease. — The  diagnosis  in 
the  early  stages  of  syphilis  is  a  matter  of  such  grave  importance  to  the  indi- 
vidual, and  may  so  seriously  affect  the  present  and  future  conduct  of  his  life, 
that  the  surgeon  should  be  very  sure  of  his  ground  before  pronouncing  a  positive 
opinion  in  the  given  case.  Among  intelligent  people,  the  belief  or  knowledge 
that  they  are  infected  with  syphilis  causes  a  degree  of  mental  anguish  which  is 
often  pitiable.  The  inauguration  of  vigorous  antisyphilitic  treatment,  a  hateful 
and  depressing  thing  in  itself,  may,  if  no  general  symptoms  develop,  leave  the 
individual  in  a  state  of  doubt  and  uncertainty  harder  to  endure,  perhaps,  than 
the  disease.  It  therefore  behooves  us  to  be  cautious  in  the  extreme,  and  by  no 
means  to  condemn  the  patient  to  several  years  of  physical  discomfort  and  some 
degree,  at  least,  of  mental  distress  until  we  are  quite  certain  that  syphilis  exists. 

The  following  considerations  may  not  be  unworthy  of  consideration:  Any 
abrasion,  herpetic  vesicle,  or  sore  of  any  sort  following  a  doubtful  coitus  should 
be  viewed  with  some  degree  of  suspicion,  and  kept  under  observation  until  the 
period  of  incubation  of  syphilis  is  past.  Any  sore  which  appears  ten  days  or 
more  after  such  a  coitus  is  decidedly  suspicious ;  if  the  base  of  the  sore  gradually 
assumes  a  characteristic  hardness  it  is  probably  a  chancre.  If,  during  the  fol- 
lowing fortnight,  the  associated  lymph  nodes  slowly  and  painlessly  enlarge,  the 
diagnosis  of  syphilis  is  almost  certain.  Should  it  now  be  possible  to  examine 
the  woman  with  whom  the  exposure  occurred,  and  should  she  be  found  suffering 


SYPHILIS  317 

from  active  syphilis  with  infecting  lesions,  the  diagnosis  is  confirmed.  Assume, 
however,  that  no  such  confrontation  is  possible,  that  the  sore  has  been  chem- 
ically or  mechanically  irritated  or  is  a  little  infected  with  pyogenic  organisms, 
the  induration  may  he  never  so  characteristic,  the  glands  of  the  groin  may 
become  enlarged,  and  yet  the  patient  may  not  have  syphilis  at  all.  He  should 
he  kept  under  observation.  If  he  has  syphilis,  general  glandular  enlargements 
and  eruptions  upon  the  skin  and  mucous  membrane  will  occur  in  due  season, 
and  he  may  then  be  got  under  the  influence  of  mercury  as  speedily  as  possible.1 

Among1  women,  the  diagnosis  of  genital  chancres  is  less  commonlv  made 
during  the  early  weeks  of  the  disease  than  among  men.  They  are  less  apt  to 
seek  early  medical  advice,  and  the  sore,  being  painless  and  often  hidden  from 
their  direct  vision,  does  not  so  early  attract  attention.  Chancre  of  the  cervix 
uteri  may  escape  notice  entirely. 

Extra-genital  Chancres. — Extra-genital  chancres  are  apt  to  be  regarded 
as  simple  lesions  for  a  time,  but  they  soon  take  on  a  definite  character,  and 
are  associated  with  characteristic  glandular  enlargements.  Chancres  upon  the 
scalp,  supra-orbital  region,  chin,  and  cheeks  form  a  rounded,  elevated,  raw 
surface,  covered  by  a  yellow  membrane  or  scab.  This  being  removed,  the  sur- 
face is  glazed  or  granular,  of  a  rather  pale-red  color,  bleeding  easily.  Indura- 
tion of  the  base  is  fairly  marked  in  some  cases,  less  so  in  others.  The  appear- 
ance is  always  suggestive  of  a  sluggish  chronic  process.  Chancres  of  the  lip 
and  of  the  mucous  membrane  of  the  mouth  and  throat  are  more  apt  to  arouse 
immediate  suspicions  of  their  nature  because  of  the  frequent  occurrence  of 
initial  lesions  in  these  regions.  Chancre  of  the  lip  is  occasionally  mistaken 
for  epithelioma.     The  differences  are  as  follows : 

Differences  from  Epithelioma.- — Chancre  may  occur  at  any  age  and  on 
either  lip.  Epithelioma  occurs  on  the  lower  lip,  usually  in  elderly  men  who 
have  habitually  smoked  a  pipe.  It  is  very  rare  in  Avomen.  The  development 
of  chancre  takes  place  in  a  few  days  or  weeks,  and  ceases  to  grow  larger. 
Epithelioma  is  usually  very  slow  in  development,  but  continues  steadily  to 
increase  in  size.  The  lymph  glands  are  enlarged  almost  at  once  in  chancre, 
not  as  a  rule  for  months  in  epithelioma.  The  appearance  of  the  "raw  surface 
may  be  rather  similar  if  covered  by  a  soft  scab,  but  the  epithelial  pearls  and 
columns  can  often  be  expressed  from  the  surface  of  an  epithelioma ;  no  such 
structures  exist  in  chancre.  The  sulphur-yellow  crusts  of  chancre  are  wanting 
in  epithelioma.  In  cases  of  doubt,  a  small  portion  of  excised  tissue  placed 
under  the  microscope  establishes  the  diagnosis,  positive  or  negative,  of  epithe- 
lioma at  once.  The  chancres  of  the  interior  of  the  mouth  begin  as  abrasions, 
excoriations,  or  papules,  which  soon  become  covered  with  a  white  or  grayish- 
white  false  membrane.  Their  failure  to  heal  under  ordinary  treatment,  the 
enlargement  of  lymph  glands,  and  sometimes  the  history,  aid  in  the  diagnosis. 

Chancres  of  the  tonsil  and  pharynx  are  usually  very  painful.      Chancres 

1  It  is  here  assumed  that  facilities  for  the  identification  of  the  Spirocheta  pallida  are  not  at 
hand. 


318  SYPHILIS    AND   LEPROSY 

of  the  nipple  begin  as  fissures,  excoriations,  or  papules ;  they  soon  become  juicy- 
looking,  elevated,  red  raw  surfaces.  The  axillary  glands  become  swollen.  If 
transmitted  by  nursing,  examination  of  the  infant  will  usually  reveal  mucous 
patches  of  the  mouth.  Chancre  of  the  finger  often  begins  at  the  side  of  the  nail, 
and  resembles  an  ordinary  paronychia.  The  induration,  the  slow  and  chronic 
course,  and  later  symptoms  establish  the  diagnosis.  On  the  dorsum  of  a  finger 
an  elevated,  rounded,  raw,  and  juicy-looking  papule  is  produced ;  the  raw  sur- 
face in  these  cases  often  reaches  a  considerable  size,  so  that  the  greater  part  of 
the  dorsal  surface  of  a  phalanx  may  be  involved.  Induration  is  not  marked 
(See  illustration.) 

Secondary  Symptoms,  Secondary  Syphilis. — Six  or  eight  weeks  after  the  ap- 
pearance of  the  initial  lesion  the  so-called  secondary  symptoms  of  syphilis  may 
be  expected  to  appear.  They  consist  of  slight  or  moderate  fever,  usually  of  brief 
duration,  often  of  headache,  which  may  be  severe  and  worse  at  night,  and  of 
neuralgic  pains  in  the  muscles,  bones,  and  elsewhere ;  these  pains  also  are  nearly 
always  worse  at  night.  The  fever  and  pain  may  be  absent  or  may  precede  or 
accompany  the  cutaneous  eruption. 

The  Blood. — A  slight  or  moderate  diminution  in  the  number  of  red  cells 
of  the  blood  has  been  noted  in  the  early  secondary  period  of  syphilis.  Diminu- 
tion in  the  content  of  hemoglobin  regularly  occurs.  This  anemia  becomes  more 
marked  as  time  goes  on,  and  in  severe  or  untreated  cases  may  reach  a  high 
grade.  The  anemia  is  improved  by  the  proper  use  of  mercury,  and  is  rendered 
worse  by  mercurial  poisoning.  In  the  tertiary  stage  with  severe  symptoms  the 
anemia  may  reach  a  profound  degree.  A  moderate  leucocytosis  accompanies 
the  anemia,  and  usually  varies  with  it ;  as  the  anemia  passes  away  under  treat- 
ment, the  leucocytes  also  diminish  in  number. 

The  Typical  and  Characteristic  Diagnostic  Signs  of  Secondary  Syphilis. — The 
typical  diagnostic  signs  of  secondary  syphilis  consist  of  a  series  of  eruptions 
appearing  upon  the  skin  and  mucous  membranes,  together  with  affections  of 
the  appendages  of  the  skin,  the  nails,  and  the  hair,  sometimes  of  inflammations 
of  the  iris,  the  joints,  etc.  The  skin  eruptions  consist  of  macules,  papules,  and 
pustules.  These  lesions  are  characterized  by  a  rather  chronic  course,  by  absence 
of  pain  and  itching,  by  a  more  or  less  characteristic  distribution,  and  by  a 
tendency  to  arrange  themselves  in  groups,  segments  of  circles,  circles,  and  fig- 
ures of  eight.  The  different  types  of  lesion — macules,  papules,  pustules — often 
exist  side  by  side ;  this  so-called  polymorphism  is  strongly  suggestive  of  syphilis. 
The  lesions  occur  in  crops ;  successive  outbreaks  come  at  irregular  intervals.  The 
earlier  eruptions  are  usually  superficial ;  the  later  outbreaks  tend  to  invade  the 
entire  thickness  of  the  skin,  to  be  of  a  more  limited  distribution,  to  run  a  more 
chronic  course,  to  be  more  destructive,  and  to  leave  permanent  scars. 

The  Macular  Syphiltde,  Syphilitic  Roseola. — The  macular  syphilide 
— syphilitic  roseola,  syphilitic  erythema — usually  the  first  eruption  to  appear, 
consists  of  rounded  or  irregularly  shaped  spots  upon  the  skin,  varying  in  size 
from  a  pin's  head  to  an  inch  in  diameter ;  they  are  not  elevated,  nor  do  they 


SYPHILIS 


319 


produce  a  palpable  infiltration.  In  color  they  vary  from  pale  pink  to  red  and 
even  purple.  The  eruption  is  often  quite  evanescent.  If  may  sometimes  be 
made  to  appear  by  exposing  the  skin  to  cold  air  or  rubbing  the  surface  of  the 
body  with  alcohol;  sometimes  the  eruption  is  general,  often  it  appears  first 


Fig.  121. — Maculo-papular  (Polymorphous)  Syphilid.     (Fox.) 


on  the  abdomen,  then  upon  the  chest,  upper  and  lower  extremities,  and  face, 
in  the  order  given.  This  anatomical  order  is  true  also  of  the  appearance  of 
the  papular  eruptions. 

The  Papular  Syphilide. — The  papular  syphilide  occurs  with  or  after 
the  roseola.  Papules  are  circumscribed  infiltrations  of  the  skin.  They  may 
be  large  or  small,  and  vary  in  character  according  to  their  anatomical  situation. 
They  may  be  dry,  or  dry  and  scaly  when  the  epidermis  is  normally  dry  and 
thick,  notably  on  the  palms  and  soles,  or  moist  and  juicy  where  the  folds  of 
skin  are  in  contact — scrotum,  labia  majora,  margin  of  anus,  beneath  the  breasts, 
etc.     The  small  papules,  known  as  miliary  papules,  are  conical  rounded  ele- 


320 


SYPHILIS    AND    LEPROSY 


vations  of  the  skin,  varying  in  size  from  a  pin's  head  to  a  quarter  of  an  inch 
in  diameter.  They  are  pale  red  or  red  in  color  when  recent,  and  assume  a 
coppery  tinge  when  old.  They  are  often  scaly  or  possess  scaly  borders  (papulo- 
squamous syphilide)  ;  they  are  to  be  distinctly  felt  by  the  finger.  If  com- 
pressed, the  red  color  disappears,  hut  leaves  a  brownish  or  copperish  stain 
behind.  They  occur  over  the  general  cutaneous  surface,  rarely  upon  the  dorsum 
of  the  hand.     Upon  the  forehead,  just  below  the  line  of  the  hair,  they  may 


Fig.   122. — Papular  Syphilid:   Confluent  on  Face.     (Fordyce.) 


form  a  grouped  eruption,  and  are  here  known  as  the  corona  veneris.  The 
larger  papules  may  be  an  inch  or  more  in  diameter ;  in  character  they  resemble 
those  just  described.  Untreated,  syphilitic  papules  run  a  chronic  course,  and 
may  remain  for  many  weeks ;  gradually  the  infiltration  disappears,  leaving  a 
very  characteristic  coppery  pigmentation  behind,  one  of  the  surest  diagnostic 
signs  of  syphilis. 

Flat  Condylomata — Moist  Papules. — As  noted,  papules  assume  a  moist 
elevated  character   when   they   occur   at  muco-cutaneous   junctions,    or   where 


SYPHILIS  321 

two  skin  surfaces  are  in  contact.  Confluent  groups  of  such  papules  in  these 
situations  are  known  as  condylomata  lata ;  they  may  form  considerable  tumors, 
and  may  be  mistaken  for  epithelioma.  They  are  often  excoriated,  covered  by 
a  false  membrane,  and,  if  neglected,  the  discharge  from  them  becomes  offensive. 
The  smaller  papules  are  sometimes  spoken  of  as  mucous  patches  in  these  situ- 
ations. Untreated,  they  may  last  for  many  months.  A  distinctive  character 
of  papular  syphilides  is  their  occurrence  upon  the  palms  of  the  hands  and 
soles  of  the  feet. 

Papules  upon  Mucous  Membbanes,  Mucous  Patches. — In  the  mouth, 
upon  the  tongue — upon  its  tip  and  lateral  borders — at  the  angles  of  the  mouth, 
the  mucous  membrane  of  the  cheeks,  upon  the  tonsils,  the  pillars  of  the  fauces, 
and  the  palatine  arch,  mucous  patches  are  regularly  present  at  some  time  dur- 
ing the  secondary  period  of  syphilis.  They  are  highly  contagious  lesions,  and 
from  their  situation  are  a  frequent  source  of  contagion.  They  form  small, 
rounded,  or  large  plaques  upon  the  surface  of  the  mucous  membrane,  sur- 
rounded by  a  narrow  red  areola  or  a  diffuse  congestion.  The  mucous  membrane 
may  appear  as  though  painted  with  nitrate-of-silver  solution,  or  be  covered 
with  a  grayish-white  false  membrane.  They  are  easily  healed  lesions,  but  recur 
with  pertinacity  from  slight  causes  of  irritation,  notably  from  the  use  of  tobacco 
and  alcohol.     They  may  be  moderately  painful. 

The  Nails,  Onychia. — Papules  occur  along  the  borders  of  the  nails. 
The  nutrition  of  the  nail  itself  may  be  affected,  the  nail  becomes  dry,  brittle, 
and  deformed.  In  some  cases  a  low  grade  of  suppuration  occurs  around  the 
base  and  matrix  of  the  nail.  The  nail  becomes  thinned  and  broken,  a  thin  or 
purulent  discharge  exudes  from  beneath  the  base  of  the  nail  and  from  the 
matrix.  The  nail  turns  brown  or  black  in  some  instances,  and  may  be  lost. 
One  or  many  nails  of  the  fingers  and  toes  may  be  affected. 

The  Pustular  Syphilides. — The  early  occurrence  of  this  form  of  erup- 
tion is  thought  to  indicate  a  grave  form  of  the  disease.  Three  types  are  de- 
scribed :  Syphilitic  acne,  Syphilitic  impetigo,  and  Syphilitic  ecthyma.  These 
lesions  are  of  a  mild  or  severe  ulcerative  character.  Syphilitic  acne  is  often 
on  the  borderland  between  a  papule  and  a  pustule.  They  form  small  conical 
projections,  a  little  serous  effusion  occurs,  which  rapidly  dries  into  a  scab  or 
crust.  They  disappear  without  scarring.  The  eruption  is  generalized,  may  be 
confluent  in  some  regions,  notably  upon  the  thighs  and  abdomen,  where  ordi- 
nary acne  is  rare.  The  crusts  and  coppery  stain  after  the  crust  separates  are 
characteristic.  Papules  and  papulo-squamous  syphilides  often  coexist.  Syphi- 
litic impetigo — localization  chiefly  face  and  scalp.  A  pustular  eruption  cov- 
ered by  crusts,  may  be  confluent,  when  large  areas  may  be  covered  with  adher- 
ent scabs.  A  copper-colored  stain  remains.  Syphilitic  ecthyma — the  lesion  is 
a  superficial  or  more  deeply  destructive  pustule  of  considerable  size.  It  may 
begin  as  a  bleb  upon  an  inflamed  base,  which  soon  becomes  converted  into  a 
large  pustule.     The  pus  dries  and  is  converted  into  a  black  crust.     This  may 

separate,  leaving  merely  a  dark  stain  without  scarring;,  or  ulceration,  deep  or 
22 


322 


SYPHILIS   AND   LEPEOSY 


superficial,  may  occur  with  scarring.  The  lesions  are  circular  in  shape.  The 
scars  are  at  first  pigmented,  and  later  turn  white.  They  are  common  upon 
the    lower    extremities.      They    are    sometimes    disseminated    and    sometimes 


Fig.  123. — Squamous  Syphilid  of  Palm.     Note  circinate  border  and  absence  of  definite  papules. 

(Fordyce.) 

grouped.  The  circular  shape  of  the  scars  is  characteristic.  Multiple  circular 
white  scars  upon  the  legs  thus  become  of  diagnostic  value  in  distinguishing 
gummata  and  other  late  lesions  from  new  growths,  etc. 


Fig.  124. — Fissured  and  Ulcerated  Eczema  of  Palm,  Simulating  an  Ulcerating  Syphilid. 

(Piffard.) 

Rtjpia. — Rupia  is  of  similar  character,  but  larger  size,  and  attended  by 
deeper  ulceration  than  ecthyma.  liupia  begins  as  a  bleb  upon  an  inflamed 
base,  circular  in  shape,  beneath  which  ulceration  of  the  shin  takes  place.  The 
crusting  is  excessive.     The  crusts  are  black.     They  continue  to  be  piled  up 


SYPHILIS 


323 


from  the  discharge  of  the  ulcer  until  they  form  a  conical  mass  of  considerable 
size.  The  entire  thickness  of  the  skin  is  destroyed.  Scarring  and  pigmentation 
result. 

Plantar  and  Palmar  Syphilides.- — The  lesions  above  described  consti- 
tute the  majority  of  the  cutaneous  accidents  which  occur  during  the  first  year 
or  two  of  syphilis.  They  may  appear,  however,  usually  in  a  discrete  form 
and  often  as  solitary  lesions,  very  late  in  the  disease.  This  is  notably  true  of 
the  plantar  and  palmar  papulo-squamous  syphilides  which  may  appear  after 
many  years  of  apparent  cure,  and  are  the  most  intractable  of  syphilitic  lesions 
of  the  integument.  I  have  recently  had  two  cases  under  my  care.  In  one, 
sixteen  years  had  elapsed  since  the  infection,  and  the  occurrence  of  round,  scaly, 
dull  red  patches  upon  the 
palms,  varying  in  size  from 
a  quarter  of  an  inch  to  three 
quarters  of  an  inch  in  diam- 
eter, associated  with  cracks 
and  fissures  in  the  skin, 
where  normal  cutaneous 
folds  existed,  were  the  first 
late  lesions  this  patient  de- 
veloped, though  I  have  had 
him  under  observation  for 
ten  years.  The  second  case 
has  been  under  my  care  with 
locomotor  ataxia  for  seven 
years.  Infection  twenty 
years  ago.  The  palmar  and 
plantar  syphilides  first  ap- 
peared about  a  year  ago. 
In  passing,  I  may  remark 
that  daily  calomel  fumiga- 
tions caused  the  lesions  to 
disappear. 

Tubercular  Syphilides  and  Guioiata. — The  later  cutaneous  lesions  of 
syphilis  are  known  as  tubercular  syphilides  and  gummata.  The  lesions  are  simi- 
lar, but  the  first  is  confined  to  the  skin;  the  second  involves  the  skin,  the  sub- 
cutaneous tissues,  and  deeper  structures.  They  usually  occur  after  two  years 
or  more,  sometimes  earlier.  Tubercular  syphilides  consist  of  elevated  infiltra- 
tions of  the  entire  thickness  of  the  skin,  usually  of  considerable  size,  single  or 
multiple,  discrete  or  confluent.  Their  favorite  situations  are  the  face,  the 
back,  the  neck,  the  lower  extremities,  and  the  muco-cutaneous  junctions.  When 
confluent,  the  lesion  may  cover  large  areas.  They  are  red,  later  copper-colored, 
and  soon  become  covered  with  thick  scales.  They  may  disappear  in  time  with- 
out ulceration,  but  leave  behind  a  scar,  at  first  pigmented,  then  white,  circular. 


Fig.  125. — Tubercular  Syphilid  of  the  Buttocks. 
(New  York  Hospital,  Out-Patient  Department.) 


324 


SYPHILIS    AND    LEPEOSY 


or  -with  wavy,  rounded  borders.  The  lesion  is  a  very  chronic  one.  Tubercular 
syphilides  sometimes  ulcerate ;  the  lesion  then  becomes  covered  by  a  crust,  and 
furnishes  an  abundant  purulent  discharge.  This  is  commonly  a  very  chronic 
lesion. 

Gummata  of  the  Skin. — As  stated,  gummata  belong  to  the  later  periods 
of  the  disease.  When  they  occur  during  the  first  year,  they  are  thought  to 
indicate  a  grave  form  of  syphilis.  The  gummatous  process  consists  essen- 
tially of  a  dense,  small-celled  infiltration  and  the  production  of  a  kind  of  tissue 
resembling  granulation  tissue,  but  poorly  supplied  with  blood-vessels,  and  prone 
to  undergo  necrosis  en  masse  with  the  production  of  a  soft,  yellowish-white, 
gelatinous,  semisolid,  gummy  material,  from  which  the  lesion  derives  its  name. 
They  may  occur  as  localized  infiltrations  and  tumors  of  varying  size  in  almost 

all  the  tissues  of  the  body.  In  the 
skin  and  subcutaneous  tissues  they 
frequently  occur  as  slowly  grow- 
ing, painless,  insensitive  nodules 
attached  to  the  skin  or  movable 
beneath  it.  Under  treatment  they 
may  disappear  without  ulceration. 
More  commonly  the  tumor  grad- 
ually softens,  the  skin  becomes  red- 
dened, fluctuation  develops,  the  skin 
is  perforated,  a  little  pus  and  gum- 
my material  is  discharged.  The 
edges  of  the  ulcer  are  mildly  red, 
circular  in  outline,  undermined. 
The  ulcer  is  deep,  covered  with  a 
yellowish-white,  necrotic,  adherent, 
soft  material;  later  on  by  pale  red, 
unwholesome  granulation  tissue.  If 
untreated,  the  ulcer  is  extraordinarily  sluggish  and  may  remain  open  for  months 
or  years. 

Ulcerating  gummata,  as  well  as  all  the  other  more  deeply  seated  syphilitic 
lesions  of  the  skin,  sometimes  take  on  what  is  known  as  a  serpiginous  charac- 
ter— that  is  to  say,  the  process  of  infiltration  and  degeneration  advances  slowly 
in  an  irregular  manner,  while  the  older  portions  of  the  lesion  heal;  thus,  a 
rounded  or  wavy  outline  of  scar  tissue  is  found  in  one  place,  a  partly  healed 
ulceration  in  another,  and  a  recent  and  advancing  process  in  a  third.  The  scars 
of  gummata  are  less  pigmented,  and  sooner  assume  a  white  color  than  do  the 
earlier  lesions  of  syphilis. 

Some  of  the  chronic  ulcerative  lesions  resemble  ulcerative  lupus;  the 
characteristic  appearances  of  tubercular  granulation  tissue  are  wanting,  as  well 
as  the  translucent  "  apple-jelly  "  like  nodules.  In  cases  of  doubt  the  adminis- 
tration of  mercury  and  of  large  doses  of  iodid  of  potash,  or  the  microscopic 


Fig.  126. — Ulcerated  Gumma  of  the  Breast. 
(Author's  collection.) 


SYPHILIS 


325 


examination  of  a  portion  of  excised  tissue,  will  make  the  diagnosis  certain. 
The  scars  of  former  ulcerative  syphilitic  lesions  arc  smooth,  circular,  or 
rounded.  The  scars  of  lupus  are  irregular  in  shape  and  of  a  puckered  uneven 
surface. 

Cutaneous  and  subcutaneous  gummata  are  frequently  multiple.  They 
may  appear  upon  any  region  of  the  body.  A  diagnostic  point  in  all  the 
syphilitic  lesions  of  the  skin  is  their  painlessness,  and  the  general  want  of 
1 1  lose  subjective  sensations,  such  as  burning,  itching,  and  the  like,  which  com- 
monly accompany  lesions  of  equal  gravity  from  other  causes.  A  further 
discussion  of  the  differential  diagnosis  of  syphilis  of  the  skin  and  mucous 
membranes  from  other  conditions  will  be  found  in  the  chapters  on  Regional 
Surgery. 

Syphilis  of  Muscles. — A  word  in  regard  to  syphilis  of  the  muscles;  gum- 
matous infiltration  occurs  with  moderate  frequency.  The  infiltration  may 
be  circumscribed  or  diffuse,  and  may  form  a  tumor  of  considerable  size  in 
the  muscles  of  the  extremity  or  trunk,  not  infrequently,  really  or  apparently, 
adherent  to  the  bone.  The  affection  simulates  quite  closely  sarcoma  of  rather 
a  firm  consistence;  many  unnecessary  operations  and  amputations  have  thus 


Fig.  127. — Syphilitic  Arthritis  of  the  Elbow.     (Collection  of  Dr.  Charles  McBurney.) 


been  performed.  Unfortunately,  even  a  microscopic  examination  does  not  ren- 
der the  diagnosis  absolutely  clear  in  every  case.  Clinically,  gummata  often 
occur  as  multiple  tumors  in  the  same  or  in  different  muscles ;  sarcoma  is  usually 
single.  Gumma,  if  it  grows  rapidly,  may  be  painful  and  tender.  It  is  more 
often  found  near  the  tendon  than  in  the  middle  of  a  muscular  belly.  If  the 
gumma  breaks  down  and  penetrates  the  skin  the  diagnosis  is  simplified.  Gumma 
does  not  tend  to  grow  beyond  certain  definite  proportions ;  sarcoma  grows  indefi- 
nitely. A  history  of  syphilis  and  large  doses  of  iodid  of  potash  aid  in  the 
diagnosis. 


326  SYPHILIS   AND   LEPROSY 

Syphilis  of  the  Bones. — (See  Diseases  of  Bones.) 

The  syphilitic  affections  of  the  brain  and  spinal  cord  have  no  direct  rela- 
tion to  surgical  diagnosis.  (See  Brain  and  Spinal  Cord.)  Syphilis  of  the 
liver,  testis,  and  other  organs  will  he  mentioned  in  the  chapters  on  Regional 
Surgery. 

Hereditary  Syphilis. — There  is  no  initial  lesion  in  hereditary  syphilis.  The 
symptoms  of  the  disease  may  appear  soon  after  birth,  or  be  deferred  for  a 
number  of  years.  The  child  may  be  born  dead,  or  "with  marked  signs  of  seri- 
ous lesions,  such  that  it  is  not  viable.  More  commonly,  the  symptoms  do  not 
appear  for  several  weeks  after  birth.  Prominent  symptoms  are  coryza;  a 
hoarse  cry  and  a  pemphigus  eruption  upon  the  skin.  Large  blebs  filled  with 
serum,  which  becomes  purulent,  form  on  various  regions.  Erythema,  papules, 
changing  later  into  pustules,  mucous  patches  in  the  mouth,  and  broad  con- 
dylomata about  the  genitals  are  common.  The  liver  is  frequently  enlarged. 
The  inflammation  of  the  epiphyses  of  long  bones  at  their  junctions  with  the 
shafts  has  already  been  described.  (See  Diseases  of  Bone.)  Iritis  and  kera- 
titis are  not  uncommon. 

Syphilitic  Teeth.— A  peculiar  deformity  of  the  permanent,  upper  mid- 
dle incisor  teeth  is  frequent,  and  is  regarded  as  diagnostic  of  hereditary  syphi- 
lis. The  teeth  are  shorter  than  normal,  narrower  at  the  cutting  edge  than  at 
the  base  of  the  tooth,  crescentically  notched  along  their  cutting  edges,  the  con- 
vexity of  the  curve  directed  toward  the  base  of  the  tooth,  and  beveled  at  the 
expense  of  the  anterior  surface — "  Hutchinson's  teeth."  (For  further  details, 
see  Regional  Surgery.) 

LEPROSY 

Leprosy  is  a  chronic  infectious  disease  caused  by  the  growth  in  the  tissues 
of  a  small  rod-shaped  bacillus — the  Bacillus  lepra1.  The  disease  is  contagious 
in  the  sense  that  persons  who  live  in  close  contact  with  leprous  individuals  are 
almost  sure  to  acquire  it  if  they  continue  among  such  surroundings  for  a  period 
of  years.  The  period  of  incubation  is  long,  sometimes  four  or  five  years.  The 
disease  is  characterized  by  the  production  of  brownish-red  spots  and  nodules 
in  the  skin,  and  in  some  cases  by  chronic  inflammation  and  thickening  of  the 
peripheral  nerves.  The  bacilli  closely  resemble  those  of  tuberculosis,  both 
in  shape  and  staining  reaction.  They  are  found  chiefly  in  the  cell  protoplasm 
of  the  round  cells  found  infiltrating  the  connective  tissue  of  the  leprous  nod- 
ules, and  in  the  scrapings  and  discharges  from  leprous  ulcers.  They  may  be 
stained  by  Gram's  method  or  with  earbol-fuchsin,  using  a  weaker  sulphuric 
acid  for  decolorizing  than  is  used  for  tubercle  bacilli,  for  lepra  bacilli  are 
more  rapidly  bleached  by  the  acid.  They  have  rarely  been  cultivated  outside 
the  human  body,  and  inoculation  experiments  in  animals  have  usually  failed. 
One  successful  inoculation  in  man  upon  the  body  of  a  condemned  criminal  was 
made  by  Arning.  A  moderate  number  of  cases  of  the  disease  exist  in  restricted 
areas  of  the  United  States,  but  the  cases  seen  here  are  most  of  them  imported 


LEPROSY  327 

from  Asia,  Scandinavia,  and  other  countries  where  the  disease  is  endemic. 
In  the  Sandwich  Islands  the  disease  occurs,  and  the  lepers  are  segregated  and 
isolated  in  the  island  of  Molokai. 

Forms  of  Leprosy. — Two  forms  of  the  disease  are  described — the  tubercular 
and  the  anesthetic — according  to  whether  the  skin  or  the  nerves  are  chiefly 
involved. 

Tubercular  Form  of  Leprosy.— In  the  tubercular  form  the  lesions 
appear  chiefly  upon  the  face,  the  hands  and  feet,  and  the  extensor  surfaces  of 
the  elbows  and  knees;  but  may  occur  almost  anywhere  upon  the  body,  except 
the  scalp,  the  palms,  and  the  soles.  Preceding  the  appearance  of  nodules  there 
occur  upon  the  skin  spots  of  pigmentation,  brown,  brownish-red,  or  dark  brown 
in  color,  varying  in  size  from  half  an  inch  in  diameter  to  several  inches. 
These  spots  may  appear  and  disappear  several  times  before  the  nodules  develop. 
The  nodules  usually  occur  upon  a  spot  previously  pigmented,  but  may  begin 
elsewhere.  They  are  rounded  or  flat,  pink,  or  yellowish-brown  soft  prominences, 
varying  in  size  from  that  of  a  pea  to  that  of  a  walnut.  Coalescence  of  the 
nodules  forms  plaques  of  various  sizes  and  shapes,  such  that  upon  the  face 
they  produce  extraordinary  and  hideous  distortion  of  all  the  features  (leonine 
leprosy).  The  tubercles  may  be  absorbed  or  break  down  and  form  shallow 
indolent  ulcers;  occasionally  the  ulcerative  process  is  rapid  and  destructive. 
Ulceration  of  the  nodules  is  said  to  be  more  common  upon  the  extremities  than 
upon  the  face.  Similar  lesions  occur  on  the  mucous  membranes  of  the  nose, 
mouth,  and  throat.  The  duration  of  life  is  indefinite.  The  patients  may  die 
of  phthisis,  nephritis,  pneumonia,  dysentery,  or  some  other  intercurrent 
disease. 

Anesthetic  Form  of  Leprosy. — This  form  of  leprosy  usually  begins  with 
a  skin  eruption  in  the  nature  of  blebs  or  spots  of  erythema ;  these  spots  are 
hyperesthetic  at  first,  later  they  become  anesthetic.  The  affected  nerve  trunks — 
the  median,  the  ulnar,  for  example — increase  in  size,  and,  in  advanced  cases, 
may  form  cords  as  thick  as  a  cigarette  or  thicker.  The  ulnar  nerve  is  fre- 
quently involved,  and  can  be  felt  enlarged  and  thickened  behind  the  internal 
condyle  of  the  humerus.  The  nerve  is  sensitive  in  the  early  stages  of  the  dis- 
ease ;  there  is  analgesia,  but  in  the  earlier  stages  no  total  loss  of  tactile  sensi- 
bility. Affections  of  the  cranial  nerves  produce  facial  paralysis  with  inability 
to  close  the  eyes.  The  analgesia  of  the  extremities  leads  to  the  continued 
unconscious  receipt  of  mechanical  and  thermal  insults  leading  to  ulcera- 
tions and  ultimate  mutilations.  Perforating  ulcer  of  the  foot  is  a  common 
occurrence.  Muscular  paralysis  occurs  in  the  affected  nerves  of  the  extrem- 
ities, and  leads  to  atrophy  of  groups  of  muscles  and  to  characteristic  de- 
formities. Gangrene  and  spontaneous  amputation  are  common  in  the  fingers 
and  toes. 

Tubercular  leprosy  may  be  confounded  with  syphilis,  prolonged  observa- 
tion of  the  case  would  make  the  diagnosis  clear.  The  negative  effect  of  mer- 
cury in  leprosy  and  its  very  rapid  curative  effect  in  syphilis  would  furnish  an 


328  SYPHILIS    AND    LEPKOSY 

ample  means  of  differentiation.  Excision  of  a  nodule  or  scraping  of  a  leprous 
ulcer  would  furnish  means  for  identifying  the  numerous  leprous  bacilli  under 
the  microscope.  The  history  of  exposure  to  leprosy,  of  course,  is  important. 
(For  the  differential  diagnosis  between  leprosy  and  various  skin  diseases  the 
reader  is  referred  to  works  on  dermatology.) 


CHAPTER    X 

DISEASES   OF   BLOOD-VESSELS 

ANEURISM 

An  aneurism  is  an  abnormal  dilatation  of  an  artery  forming  a  cavity 
through  which  blood  from  the  artery  circulates.  Aneurism  may  result  from 
disease  of  the  vessel  wall,  atheroma,  endarteritis  syphilitica,  or  other  degen- 
erative change,  or  from  injury — stretching  or  tearing  of  one  or  more  of  the 
arterial  coats,  or  from  an  open  wound  of  the  vessel.  As  the  result  of  disease 
a  uniform  dilatation  of  some  limited  section  of  the  arterial  wall,  including 
its  entire  circumference,  leads  to  an  aneurism  of  cylindrical  or  fusiform  shape — 
cylindrical  aneurism  or  fusiform  aneurism.  If  the  arterial  wall  gives  way  or 
becomes  dilated  over  a  limited  area  not  involving  the  entire  circumference  of 
the  vessel  a  sac  is  formed  of  greater  or  less  size,  communicating  with  the  caliber 
of  the  vessel  more  or  less  freely,  through  a  comparatively  narrow  orifice — 
sacculated  aneurism.  Many  sacculated  aneurisms  are  due  to  traumatic  and 
mechanical  causes.  When  an  aneurism  bursts  subcutaneously  and  blood  is 
extravasated  more  or  less  widely  into  the  surrounding  tissues  the  condition  is 
known  as  diffuse  aneurism  or  secondary  aneurismal  hematoma.  A  direct  wound 
of  an  artery,  or  its  rupture  by  direct  violence,  followed  by  the  formation  of 
a  tumor  composed  of  clotted  and  fluid  blood,  is  also  sometimes  called  diffuse 
aneurism,  or  arterial  hematoma,  or  primary  aneurismal  hematoma.  A  wound 
which  involves  simultaneously  an  adjacent  artery  and  vein  may  lead  to  a  per- 
manent abnormal  communication  between  the  artery  and  the  vein.  If  the 
communication  is  close  and  immediate,  the  condition  is  known  as  aneurismal 
varix.  If  a  sac  forms  between  the  artery  and  the  vein  and  communicating 
with  both,  the  condition  is  known  as  varicose  aneurism.  Both  types  are  in- 
cluded under  the  general  title  of  arterio-venous  aneurism.  When  the  internal 
coat  of  an  artery  gives  way  and  blood  finds  its  way  along  the  substance  of  the 
middle  coat,  or  between  it  and  the  outer  coat,  the  condition  is  known  as  dis- 
secting aneurism.  It  occurs  only  in  the  aorta,  and  is  of  no  surgical  interest. 
The  cylindrical,  fusiform,  and  sacculated  dilatations  of  arteries,  as  well  as 
those  injuries  of  arteries  followed  by  the  escape  of  blood  from  the  artery  and 
its  accumulation  in  the  surrounding  tissues,  with  the  formation  of  a  cavity 
whose  walls  are  composed  of  the  tissues  displaced  by  arterial  blood-pressure 

and  lined  by  connective  tissue,  fibrin,  and  blood-clot,  and  filled  with  fluid  blood 

329 


330  DISEASES    OF   BLOOD-VESSELS 

communicating  directly  with  the  caliber  of  the  wounded  vessel,  form  a  group 
of  conditions  usually  known  as  circumscribed  aneurism.  Cirsoid  aneurism  has 
already  been  described  under  the  head  of  Tumors. 

Symptoms  of  Aneurism. — The  subjective  symptoms  accompanying  aneurism 
are  due  chiefly  to  its  increase  in  size,  whereby  it  causes  pressure  upon  nerve 
trunks,  bones,  veins,  interference  with  hollow  canals,  or  organs,  etc. ;  and  these 
symptoms  will,  of  course,  vary  with  the  size  and  situation  of  the  aneurism. 
Aneurisms  in  the  extremities  cause  more  or  less  pain,  sometimes  of  a  dull 
and  aching  character ;  sometimes  sharp  and  neuralgic ;  sometimes  muscular 
weakness,  limitation  of  motion  in  joints,  as,  for  example,  in  the  knee-joint  in 
popliteal  aneurism.  By  pressure  upon  veins,  edema  and  congestion  of  the 
extremity  may  occur.  Intrathoracic  aneurisms  may,  by  pressure  upon  the  in- 
nominate vein,  cause  attacks  of  sudden  and  intense  venous  congestion  of  the 
face  and  neck,  with  giddiness,  or  dyspnea  from  pressure  upon  the  trachea,  or 
difficulty  in  swallowing  from  pressure  upon  the  esophagus.  A  further  growth 
of  the  aneurism  may  cause  paralysis  of  nerve  trunks  by  pressure,  a  change 
in  the  voice  by  pressure  on  the  recurrent  laryngeal  nerve. 

Physical  Signs.— The  physical  signs  of  circumscribed  aneurism  are,  the 
existence  of  a  smooth,  rounded,  sharply  circumscribed,  rather  soft,  fluctuating, 
elastic,  and  pulsating  tumor  situated  over  the  course  of  an  artery.  The  size 
of  circumscribed  aneurism  varies  from  an  inch  to  three  inches  in  diameter, 
rarely  more,  except  those  of  the  aorta.  The  tumor  is  readily  compressible,  but 
returns  immediately  to  its  former  size  as  soon  as  the  pressure  is  relieved.  The 
pulsation  of  aneurism  is  peculiar  in  that  if  the  tumor  be  deeply  grasped  with 
the  fingers  they  may  be  felt  and  seen  to  separate  a  little  with  each  pulsation, 
and  the  expansion  is  felt  on  both  sides  alike — "  expansile  pulsation."  By 
auscultation  over  the  aneurism  a  soft  or  harsh  blowing  murmur  can  usually 
be  heard  synchronous  with  the  pulsation. 

If  the  main  artery  be  compressed  between  the  aneurism  and  the  heart, 
pulsation  in  the  aneurism  as  well  as  the  murmur  cease,  and  the  tumor,  if  the 
aneurism  is  of  recent  formation,  may  diminish  in  size  or  disappear.  Pressure 
upon  the  affected  artery  distal  to  the  tumor  causes  the  aneurism  to  increase 
in  size.  The  pulsation  in  arteries  distal  to  the  aneurism  is  usually  weaker 
than  on  the  sound  side  of  the  body,  and  delayed,  as  can  often  be  demonstrated 
by  sphygmographic  tracings  of  the  two  vessels,  or  by  comparing  the  characters 
of  the  pulse  on  both  sides  of  the  body  at  the  same  time,  a  finger  being  placed 
on  each.  If  the  aneurism  is  deeply  placed,  so  that  it  cannot  be  easily  palpated, 
some  or  all  of  these  signs  may,  of  course,  be  wanting.  In  old  aneurisms  the 
sac  may  be  greatly  thickened  by  deposits  of  fibrin,  and  the  opening  into  the 
vessel  may  be  small.  The  signs  of  pulsation  and  murmur  may  then  be  greatly 
obscured  or  absent.  The  aneurism  may  have  undergone  consolidation  and 
spontaneous  cure.  A  solid  tumor  connected  with  the  artery  will  then  be  pres- 
ent. In  cases  of  subcutaneous  rupture  of  aneurism  the  signs  of  swelling 
and  inflammation  may  entirely  overshadow  or  completely  hide  the  signs  of 


ANEURISM 


331 


aneurism  itself;  later,  a  secondary  sac  may  form  in  which  pulsation  and  bruit 
may  develop. 

Pyogenic  infection  and  suppuration  of  an  aneurismal  sac  is  a  rare  and 
grave  accident,  it  is  attended  by  general  symptoms  of  sepsis,  fever,  often  a  chill, 
a  rapid  pulse,  prostra- 
tion, etc.  Locally,  the 
signs  of  acute  inflamma- 
tion arc  present  in  the 
tissues  covering  the  aneu- 
rism, the  pulsation  and 
bruit  may  cease.  Pain 
is  a  very  marked  symp- 
tom. Pressure  upon  the 
veins  may  cause  their 
occlusion,  with  swelling 
and  edema  of  the  limb. 
Thrombosis  of  the  artery 
is  not  an  uncommon  com- 
plication, and  the  com- 
bined interference  with 
the  arterial  and  venous 
circulation  often  leads  to 
gangrene  of  the  limb.  In 
other  cases  an  abscess 
forms  in  and  around  the 
aneurism  which  may  per- 
forate the  skin,  burst,  and 
be  accompanied  by  dan- 
gerous or  fatal  bleeding.  Mild  noninfectious  inflammation,  with  swelling, 
edema,  redness,  and  tenderness  of  the  overlying  skin,  is  not  uncommon  during 
the  growth  of  an  aneurism.  It  may  be  accompanied  by  clotting  of  the  blood 
in  the  sac  and  cure  of  the  aneurism.  The  growth  of  the  intrathoracic  aneu- 
risms is  often  attended  by  absorption  of  bone  by  pressure — the  sternum,  the 
ribs,  the  vertebra?.  Deep-seated  abscesses  of  the  anterior  thoracic  wall  should 
always  be  regarded  as  possible  aneurisms.  A  careful  examination  should  be 
made  for  pulsation  and  bruit. 

Course  of  Aneurism. — The  ordinary  course  of  aneurism  is  toward  final  rup- 
ture ;  when  this  takes  place  into  the  large  body  cavities,  the  pleura,  pericardium, 
peritoneum,  sudden  or  speedy  death  is  the  rule.  Aneurisms  which  burst  out- 
wardly cause  first  a  thinning  and  discoloration  of  the  skin,  later  necrosis.  The 
rupture  may  be  through  a  large  orifice  and  cause  rapidly  fatal  bleeding,  or 
through  a  small  one,  which  may  be  plugged  by  a  clot  after  a  greater  or  less 
quantity  of  blood  has  escaped.  Bleeding  is,  however,  sure  to  recur,  and  will 
be  fatal  unless  the  vessel  can  be  ligated,  or  Matas'  operation  be  done. 


Fig.  128. — Aneurism  op  the  Common  Femoral  Artery  in  Scar- 
pa's Triangle.      (New  York  Hospital  collection.) 


332  DISEASES    OF   BLOOD-VESSELS 

Diagnosis. — The  diagnosis  of  aneurism  in  its  earlier  stages,  when  so  placed 
that  it  is  readily  accessible  to  examination,  is  absolutely  simple,  the  signs  are 
characteristic  and  resemble  no  other  lesion.  When  inaccessible  to  palpation, 
they  may  pass  unrecognized  or  be  recognized  with  difficulty.  When  the  sac 
has  become  greatly  thickened  by  the  deposition  of  laminated  blood  clots,  the 
characteristic  signs  may  be  wanting,  or  so  faint  as  not  to  be  detected.  Such 
aneurisms  may  be  mistaken  for  solid  tumors,  for  cysts,  or  for  abscesses.  I 
have  seen  an  aneurism  of  the  external  iliac,  which  presented  in  the  groin 
as  a  fluctuating  swelling  covered  by  red  and  inflamed  skin,  diagnosticated  as 
a  suppurative  inguinal  adenitis  by  an  experienced  surgeon.  Any  tumor  or 
apparent  abscess  which  overlies  the  course  of  a  large  artery  should  be  examined 
with  great  care  for  the  signs  of  aneurism. 

The  mistake  of  supposing  that  a  tumor  of  any  sort  overlying  a  large  arterial 
trunk  is  an  aneurism  may  easily  be  made;  this  is  due  to  the  fact  that  such 
tumors  may  exhibit  a  pulsation  transmitted  to  them  by  the  artery.  The  pul- 
sation of  such  tumors  is  not  expansile,  but  if  the  examining  fingers  cannot  be 
pressed  into  the  tissues  far  enough  to  grasp  the  widest  portion  of  the  tumor, 
the  sensation  transmitted  may  be  that  of  expansile  pulsation,  because  as  the 
tumor  is  lifted  by  the  artery  it  may  be  pressed  up  between  the  fingers  as  a 
wedge,  thus  separating  them.  If  the  tumor  can  be  pushed  to  one  side  of  the 
artery,  or  lifted  away  from  it,  the  pulsation  will  cease.  The  tumors  most 
likely  to  be  mistaken  for  aneurism  are  the  very  vascular  sarcomata  and  car- 
cinomata ;  they  also  may  exhibit  expansile  pulsation,  but  they  are  rarely  so 
soft  as  to  give  the  sensation  of  fluctuation,  nor  can  they  be  diminished  in  size 
by  pressure  to  the  same  extent  as  an  aneurism,  nor  do  they  suffer  the  same 
diminution  in  size  when  the  main  artery  of  the  limb  is  compressed. 

ARTERIO-VENOUS    ANEURISM 

Arterio-venous  aneurism  signifies  an  abnormal  communication  between  an 
artery  and  a  vein.  The  condition  arises  most  often  as  the  result  of  a  wound 
which  opens  the  artery  and  the.  vein  at  the  same  time.  In  some  cases  a  rup- 
ture of  an  aneurism  may  take  place  into  a  vein,  and  in  still  others  it  appears 
that  the  aneurism  has  occurred  spontaneously  from  disease  of  the  arterial  and 
venous  walls. 

During  the  days  when  venesection  was  largely  practiced  the  unskillful  use 
of  the  lancet  at  the  bend  of  the  elbow  and  the  simultaneous  wounding  of  a 
vein  and  of  the  brachial  artery  produced  in  a  good  many  cases  an  arterio-venous 
aneurism.  At  the  present  time  they  are  rare  in  this  situation,  but  occasionally 
occur  as  the  result  of  stab  wounds  and  bullet  wounds  which  accidentally  wound 
an  artery  and  a  vein.  They  may  rarely  be  due  to  fractures,  and  occur  in  frac- 
tures of  the  base  of  the  skull,  from  an  edge  of  bone  which  wounds  at  once  the 
internal  carotid  artery  and  the  cavernous  sinus. 

The  spontaneous  variety  usually  arise  in  the  aorta;   sometimes  the  com- 


ARTERIO-VENOTTS    ANEURISM  333 

mimication  is  with  the  pulmonary  vein,  or  in  the  abdominal  aorta  with  the 
vena  cava,  in  the  traumatic  variety  the  opening  in  the  artery  may  lead  directly 
into  the  vein,  or  there  may  be  formed  an  intermediate  aneurismal  sac  between 
the  vessels — aneurismal  varix  and  varicose  aneurism  respectively.  The  aneu- 
rismal sac,  if  one  be  present,  may  be  formed  of  connective  tissue,  or  from  the 
wall  of  the  dilated  vein  itself. 

Signs  and  Symptoms. — The  signs  and  symptoms  produced  will  vary  in  sever- 
ity according  to  the  relative  size  of  the  artery  and  of  the  vein.  If  the  artery 
be  small  and  the  vein  large,  so  that  it  can  readily  dispose  of  the  additional 
flow  of  blood,  the  symptoms  may  be  slight  or  absent.  If  the  artery  is  large 
and  the  vein  small,  the  vein  and  its  branches  become  enlarged,  varicose, 
and  tortuous  on  the  distal  side  of  the  abnormal  opening,  and  serious  and 
even  grave  disturbances  of  the  circulation  and  nutrition  of  the  part  may 
follow. 

When  due  to  an  open  wound,  the  symptoms  are  usually  not  long  in  making 
their  appearance.  The  wound  often  bleeds  freely,  but  the  hemorrhage  is  usu- 
ally controllable  by  pressure.  The  wound  in  the  skin  heals  in  the  ordinary  way, 
and  usually  after  a  short  time  the  characteristic  sign  of  this  form  of  aneurism 
is  noticed — the  so-called  thrill.  The  thrill  can  be  felt  by  placing  the  hand  over 
the  seat  of  the  injury.  A  murmur  can  be  heard  by  placing  the  ear  or  a 
stethoscope  over  the  opening  between  the  artery  and  the  vein,  and  usually  for 
some  distance  above  and  below  that  point.  The  thrill  is  continuous,  and  has 
been  likened  to  the  purring  of  a  cat,  the  noise  made  by  a  bluebottle  fly  when 
buzzing  in  the  interior  of  a  thin  paper  bag,  and  to  other  similar  vibratory 
phenomena.  The  murmur  also  is  continuous,  with  rhythmic  changes  in  in- 
tensity corresponding  to  the  pulsations  of  the  heart.  In  addition  there  may 
be  swelling  of  the  limb  in  the  neighborhood  of  the  wound,  dilatation  of  the 
superficial  veins,  or  the  formation  of  a  definite,  circumscribed  tumor  which 
gives  the  sign  of  expansile  pulsation,  indicating  the  formation  of  a  sac.  In 
the  limbs  the  dilated  veins  may  also  pulsate. 

The  later  'progress  of  the  disease  varies  greatly.  The  varicose  condition 
of  the  veins  may  increase  and  become  so  extensive  as  to  involve  most  of  the 
superficial  veins  of  the  extremity.  In  other  cases  the  enlargement  will  be 
slight.  There  are  sometimes  disturbances  of  sensation  in  the  limb,  such  as 
numbness,  tingling,  and  neuralgic  pains.  The  nutrition  of  the  limb  may  also 
be  disturbed;  there  may  be  weakness  of  the  muscles;  the  limb  may  be  perma- 
nently swollen ;  chronic  dermatitis,  sometimes  with  ulceration,  may  develop 
upon  the  skin.  In  some  instances  the  disease  may  become  stationary ;  in  others 
it  may  continue  to  grow  worse,  even  to  the  extent  of  producing  a  rupture  of 
the  aneurismal  sac  externally. 

Forms. — If  the  artery  and  the  vein  are  in  close  contact  so  that  the  blood 
passes  from  the  artery  to  the  vein  without  any  space  between,  the  condition 
is  known  as  aneurismal  varix.  The  vein  and  all  its  branches  may  become 
enlarged  and  varicose.     If,  however,  some  space  exists  between  the  artery  and 


334  DISEASES    OF  BLOOD-VESSELS 

the  vein,  and  a  sac  is  formed  communicating  on  the  one  hand  with  the  artery 
and  on  the  other  with  the  vein,  the  condition  is  known  as  varicose  aneurism. 
It  is  not  always  possible  to  distinguish  the  two  forms  by  external  examination, 
notably  if  the  vessels  are  deeply  seated.  The  diagnostic  signs  of  the  condition 
are  usually  present  soon  after  the  injury,  although  some  of  the  results  of  the 
abnormal  communication  only  develop  gradually  after  some  time  has  elapsed. 
As  in  other  punctured  wounds  of  arteries,  sharp  bleeding  may  take  place  at 
once,  and  a  mixture  of  arterial  and  venous  hemorrhage  has  been  noted  in 
certain  cases ;  such  hemorrhage  soon  ceases,  and  the  wound  usually  heals  with- 
out delay. 

Diagnostic  Signs. — The  diagnostic  signs  are  a  thrill,  felt  when  the  palm  of 
the  hand  is  placed  over  the  seat  of  the  injury;  this  sensation  is  readily  appre- 
ciated in  all  cases  except  where  the  vessels  are  very  deeply  placed.  The  mur- 
mur is  readily  heard  through  the  stethoscope  placed  over  the  site  of  the  wounded 
vessel.  It  is  usually  heard  most  plainly  at  this  point,  and  is  often  a  continuous 
murmur,  which  is,  however,  louder  during  the  systolic  pulsation  of  the  artery. 
It  may  also  be  heard  for  some  distance  above  and  below  the  point  of  injury, 
but  less  distinctly  and  not  continuously. 

In  case  a  considerable  sac  is  formed  between  the  vessels,  a  pulsating  tumor 
may  be  produced  similar  to  ordinary  circumscribed  aneurism.  The  veins,  also, 
may  pulsate  for  a  considerable  distance  from  the  seat  of  the  injury.  Inter- 
ference with  the  circulation  produces  swelling  of  the  limb  and  disturbances  of 
its  nutrition,  sometimes  a  higher  temperature,  and  sometimes  degenerative 
changes  in  the  skin.  There  may  be  also  subjective  sensations,  such  as  pain 
along  the  course  of  the  nerves,  disturbances  in  sensation  of  the  skin,  and 
sometimes  muscular  spasms  and  weakness.  The  veins  communicating  with 
the  artery  will  be  increased  in  size  in  varying  degrees,  according  to  the  relative 
size  of  the  orifice  in  the  artery  and  the  size  of  the  vein  into  which  it  empties. 
If  the  orifice  in  the  artery  be  small  and  if  the  vein  be  large,  but  slight  changes 
may  be  observed.  If,  on  the  other  hand,  the  orifice  in  the  artery  is  of  con- 
siderable size  and  the  vein  not  large,  great  distention  and  enlargement  of  all 
the  veins  of  the  region  may  take  place. 

INFLAMMATION    OF    THE    BLOOD-VESSELS 

Acute  Inflammation  of  the  Arteries. — Acute  inflammation  of  the  arteries 
occurs  chiefly  as  the  result  of  the  lodgment  of  an  infected  embolus  in  the  course 
of  pyemia.  The  symptoms  and  signs  are  those  of  pyemic  abscess,  already 
described.  Suppuration  of  the  interior  of  an  aneurismal  sac  is  spoken  of 
under  the  head  of  aneurism.  Suppurative  arteritis  may  also  occur  from  direct 
infection  of  the  arterial  wall  itself,  as  in  a  suppurating  wound.  Necrotic 
inflammation  of  the  vessel  wall  may  occur,  with  rupture  and  serious  bleeding; 
the  secondary  hemorrhage  which  followed  amputations  and  other  operations 
in  preantiseptic  days  was  of  this  description ;  it  is  now  rarely  seen. 


INFLAMMATION    OF    THE   BLOOD-VESSELS  335 

Chronic  Inflammation  of  the  Arteries. — Chronic  inflammation  of  the  arteries 
is  of  two  kinds : 

(1)  Atheromatous  Degeneration. —  The  so-called  atheromatous  degen- 
eration occurring'  in  middle  or  later  life,  is  attended  by  thickening  and  rigidity 
of  the  arterial  coats,  with  the  deposition  of  lime  salts  in  the  wall  of  the  artery, 
fatty  degeneration,  and  sometimes  loss  of  intima.  Thrombi  may  form  in  such 
situations,  and  portions  of  these  being  washed  away  may  cause  embolism.  In 
small  arteries  the  caliber  of  the  artery  may  be  diminished,  or  even  occluded 
(see  Gangrene).  General  arterial  atheroma  and  sclerosis  are  often  associated 
with  cardiac  and  renal  disease,  and  the  condition  adds  some  small  danger  to 
the  administration  of  anesthetics  and  to  surgical  operations. 

(2)  Syphilitic  Inflammation  of  the  Arteries. — One  of  the  common 
lesions  following  syphilis  affects  groups  of  smaller  vessels,  notably  the  arteries 
of  the  brain,  and  causes  sometimes  obliteration  of  their  caliber — syphilitic 
obliterating  endarteritis.  Sudden  interference  with  the  nutrition  of  the  brain, 
causing  attacks  resembling  apoplexy,  or  more  gradual  interference,  causing 
progressive  cerebral  symptoms,  headache,  limited  palsies,  etc.,  are  usually  due 
to  syphilis  when  they  occur  in  persons  under  forty-five  years  of  age. 

Diseases  of  Veins — Acute  Phlebitis. — Acute  infectious  inflammation  of  veins 
occurs  as  the  result  of  infected  wounds  of  the  vein  itself  or  of  the  neighboring 
tissues.  In  the  course  of  pyemia,  osteomyelitis,  erysipelas,  suppurative  inflam- 
mation of  the  middle  ear,  as  an  extension  from  an  infected  ulcer,  etc.  Ante- 
cedent to  or  in  consequence  of  the  infection  the  blood  in  the  vein  coagulates, 
forming  a  thrombus.  Such  thrombi  often  begin  upon  one  of  the  valves  of  the 
vein.  Purulent  softening  of  thrombi  and  their  entrance  into  the  general  circu- 
lation causes  pyemia.  Acute  purulent  inflammation  and  thrombosis  of  veins 
usually  forms  but  a  part  of  the  symptom-complex  of  severe  septic  diseases.  If 
the  vein  is  superficial  and  of  an  extremity,  in  addition  to  the  general  septic 
symptoms,  the  vein  will  feel  like  a  hard,  tender  cord.  A  periphlebitis  is 
usually  present,  and  some  induration  of  the  subcutaneous  tissues.  The  course 
of  the  vein  may  be  marked  upon  the  skin  by  a  blood-red,  tender  streak.  If 
the  deep  veins  are  infected  and  thrombosed,  the  superficial  veins  will  be  dilated. 
If  the  vein  is  large,  like  the  femoral  vein,  and  constitutes  the  principal  vein 
of  the  extremity,  swelling  and  edema  of  the  limb  will  be  marked.  Abscesses 
may  occur  along  the  course  of  the  vein,  and  give  rise  to  characteristic  signs  and 
symptoms. 

Periphlebitis  and  phlebitis  of  a  less  severe  type  is  a  common  complication 
of  varicose  veins  of  the  leg  with  varicose  ulcer.  It  may  also  follow  superficial 
infected  wounds.  The  process  is  mostly  confined  to  the  outer  coats  of  the  vein 
and  the  surrounding  connective  tissues,  and  affects  one  or  more  superficial 
veins.  Thrombosis  of  the  vein  may  or  may  not  occur.  The  symptoms  are  pain 
in  the  limb,  a  red,  broad  band  on  the  skin  in  the  course  of  the  veins,  and  the 
presence  of  a  hard  cord  beneath  it.  Abscess  may  occur  in  the  course  of  the  vein, 
or  thrombosis  of  the  vein  with  organization  of  the  thrombus ;  the  vein  then 


336  DISEASES    OF   BLOOD-VESSELS 

remains  impervious  as  a  subcutaneous  cord.  Deposition  of  lime  salts  may  take 
place  in  the  thrombus  and  form  the  so-called  vein  stones  palpable  in  the  course 
of  the  vein  beneath  the  skin. 

Thrombosis. — Thrombosis  of  veins  may  occur  not  only  as  the  result  of  purely 
septic  conditions,  but  also  from  chronic  disease  of  the  vessel  wall,  or  be  due 
to  traumatism,  rheumatism,  syphilis,  the  acute  infectious  fevers,  any  cause 
which  diminishes  the  rapidity  of  the  circulation.  Thrombi  may  form  in  either 
arteries  or  veins,  and  may  partly  or  entirely  fill  the  lumen  of  the  vessels.  They 
may  be  absorbed  or,  if  infected,  undergo  purulent  softening,  or  become  organ- 
ized, or  cause  obliteration  of  the  vessel.  Infected  thrombi  produce,  as  already 
stated,  localized  abscesses  and  obliteration  of  the  vein,  or  pyemia.  Thrombosis 
of  arteries  is  less  common  than  is  the  case  with  veins. 

Symptoms. — The  symptoms  of  thrombosis  vary  much,  according  to  whether 
or  not  the  thrombi  are  infectious,  and  to  the  situation  and  character  of  the 
vessel  in  which  they  form.  The  sudden  formation  of  a  thrombus  which  oc- 
cludes a  large  artery,  such  as  the  main  artery  of  an  extremity,  are  sudden, 
violent  pain  in  the  limb,  frequently  complete  loss  of  muscular  power.  These 
symptoms  may  be  followed  by  gradual  or  partial  recovery,  or  according  to 
whether  collateral  circulation  is  established  or  not,  occasionally  by  gangrene 
of  the  extremity.  This  condition  is,  however,  a  rare  one  unless  the  accom- 
panying veins  are  thrombosed  at  the  same  time,  or  unless  the  lumen  of  all  the 
arteries  of  the  extremity  has  been  previously  narrowed  by  antecedent  disease 
of  the  vessel  walls.  I  saw  thrombosis  of  the  left  common  iliac  artery  in  a 
syphilitic,  alcoholic  young  man  cause  gangrene  of  the  entire  lower  extremity 
and  death.  The  larger  arteries  of  the  extremity  were  everywhere  filled  with 
thrombi  at  the  time  the  limb  was  amputated. 

Embolism. — An  embolus — from  the  Greek  word  meaning  a  plug — is  usually 
derived  from  a  thrombus,  infected  or  noninfected,  or  from  fibrinous  vegetations 
forming  on  the  valves  of  the  heart,  from  globules  of  fat  derived  from  a  recent 
fracture,  from  air  which  has  entered  a  wounded  vein  at  the  root  of  the  neck, 
from  a  portion  of  fibrin  derived  from  the  sac  of  an  aneurism,  or  a  portion  of 
a  malignant  tumor  which  has  invaded  the  wall  of  a  vein.  The  embolus  derived 
from  any  of  these  sources  enters  the  venous  or  arterial  blood-current,  and  is 
carried  by  that  current  until  it  lodges  in  a  vessel  so  small  that  it  cannot  pass. 
Emboli  derived  from  veins  enter  the  right  side  of  the  heart  or  the  liver  and 
lodge  in  the  lungs,  usually,  or  in  the  liver  if  they  are  formed  in  the  portal 
circulation.  Those  which  are  derived  from  the  left  side  of  the  heart,  or  have 
passed  through  the  lungs  and  enter  that  side  of  the  heart,  finally  lodge  in  some 
artery  of  the  body  so  small  that  they  cannot  further  pass. 

If  the  emboli  are  infectious,  they  produce  metastatic  abscesses  or  specific 
infiltrations  (tuberculosis),  etc.,  as  already  indicated.  If  they  are  noninfec- 
tious, they  produce  disturbances  of  circulation  and  of  nutrition  and  function 
which  vary  in  character  and  intensity  with  the  size  and  situation  of  the  vessel 
plugged.     In  the  brain  they  produce  paralyses  or  death.     If  they  lodge  in  an 


INFLAMMATION   OF    THE   BLOOD-VESSELS  337 

arterial  trunk  of  one  of  the  extremities,  they  produce  disturbances  of  circula- 
tion and  nutrition  in  the  limb  which  vary  in  intensity  according  to  the  size 
of  the  artery  plugged  and  the  general  nutrition  of  the  individual.  If  the 
main  artery  of  a  limb  is  occluded  by  an  embolus,  partial  gangrene  of  the  ex- 
tremity is  an  occasional  result.  If  the  general  circulation  of  the  individual 
is  in  good  order,  gangrene  will  rarely  occur  with  proper  care  and  treatment. 

Signs  and  Symptoms. — The  signs  and  symptoms  of  the  lodgment  of  an 
embolus  in  a  large  artery  of  an  extremity  are  sudden  violent  pain  in  the  parts 
supplied  by  the  artery,  loss  or  diminution  of  muscular  power.  The  skin  be- 
comes pale  and  cold ;  there  is  a  subjective  sensation  of  numbness,  sometimes 
hyperesthesia  followed  by  loss  of  sensibility  if  gangrene  is  threatened.  The 
subsequent  history  is  that  of  gangrene  in  unfavorable  cases,  and  of  a  gradual 
return  to  normal  if  the  collateral  circulation  is  established. 

Varicose  Veins. — Veins  which  become  dilated  or  tortuous,  with  or  without 
a  notable  thickening  of  their  walls,  are  known  as  varicose  veins.  The  condition 
may  be  due  to  a  variety  of  causes ;  to  mechanical  interference  with  the  flow 
of  blood  through  the  veins,  as,  for  example,  in  cirrhosis  of  the  liver,  the 
portal  circulation  being  interfered  with,  the  blood  cannot  any  longer  freely 
traverse  the  liver  and  must  seek  other  channels ;  under  such  circumstances  the 
veins  of  the  anterior  abdominal  wall  become  enlarged  and  varicose.  The 
pressure  of  a  tumor  of  the  kidney  upon  the  spermatic  veins  may  cause  their 
original  branches  to  become  varicose. 

In  certain  situations  a  very  long  column  of  blood  must  be  raised  against 
gravity  in  its  return  to  the  heart;  this  is  notably  true  of  the  superficial  veins 
of  the  lower  extremity,  and  in  persons  whose  bodies  are  not  very  well  nour- 
ished, or  whose  tissues  are  flabby  and  who  are  obliged  to  be  much  upon  their 
feet,  a  varicose  condition  of  the  superficial  veins  of  the  leg  is  a  frequent  occur- 
rence. The  disease  is  of  slow  development,  and  does  not  usually  give  rise  to 
very  marked  symptoms  until  middle  life,  although  it  is  sometimes  observed  in 
young  adults,  apparently  as  the  result  of  a  congenital  weakness  of  structure 
or  of  incompetence  of  the  valves  of  the  veins  of  the  lower  extremity.  The 
disease  is  much  more  common  in  women  than  men,  probably  as  the  result  of 
venous  obstruction  during  pregnancy. 

Signs  and  Symptoms  of  Varicose  Veins  of  the  Leg. — The  veins  form 
tortuous,  rounded,  columnar  eminences  upon  the  front  and  sides  of  the  leg 
extending  from  the  ankle  up  to  the  knee,  and  in  some  cases  along  the  inner 
and  anterior  aspect  of  the  thigh  as  far  as  the  saphenous  opening.  In  thin- 
skinned  individuals  they  may  have  a  blue  color.  Fusiform  or  bulbous  enlarge- 
ments of  the  veins  may  sometimes  be  observed,  and  indicate  the  position  of 
valves.  The  veins  grow  smaller  or  disappear  when  the  patient  lies  down.  Upon 
palpation  the  veins  are  soft  and  compressible,  and  insensitive  unless  inflamed. 
They  vary  much  in  size ;  if  the  smaller  veins  are  affected  they  will  be  quite 
small,  but  very  numerous.  In  ordinary  cases  there  will  be  four  or  five  or  more 
of  the  larger  veins  and  their  communicating  branches  involved ;  these  may 
23 


338 


DISEASES   OF  BLOOD-VESSELS 


be  as  large  as  a  lead  pencil,  or  even  as  a  good-sized  finger.  If  the  saphenous 
vein  is  varicose  at  the  saphenous  opening,  it  may  simulate  a  femoral  hernia. 
Both  are  apt  to  disappear  when  the  patient  lies  down.    Pressure  upon  a  femoral 

hernia  at  the  saphenous  opening  will 
prevent  its  descent ;  pressure  at  the  same 
point  will  only  make  varicose  veins 
appear  larger. 

The  subjective  symptoms  of  vari- 
cose veins  are  slight  at  first ;  later  there 
will  be  a  sense  of  fullness  or  dull  pain 
in  the  limb.  After  the  varicose  veins 
have  existed  for  some  time,  the  nutri- 
tion of  the  skin  of  the  limb  suffers,  and 
a  chronic  eczema  of  the  leg,  with  acute 
exacerbations,  is  developed.  As  the  re- 
sult of  scratching  or  of  slight  trauma- 
tisms an  ulcer  forms  frequently  at  the 
junction  of  the  middle  with  the  lower 
third  of  the  leg.  These  ulcers  are  apt 
to  become  chronic.  The  frequent  attacks 
of  eczema  produce  pigmentation  of  the 
skin,  and  the  skin  becomes  indurated 
and  thickened  from  the  chronic  inflam- 
mation. The  ulcers  slowly  increase  in 
size,  and  may  even  entirely  encircle  the 
extremity.  In  neglected  cases  attacks 
of  acute  infection  of  the  ulcer  occur 
from  time  to  time,  leading  to  necrotic 
inflammation  of  the  base  of  the  ulcer, 
sometimes  to  gangrene  with  putrid  decomposition  of  the  raw  surface.  Such 
gangrene  is,  however,  limited  to  the  base  of  the  ulcer.  Involvement  of  the 
wall  of  one  of  the  dilated  veins  in  the  ulceration,  or  the  accidental  wounding 
of  such  a  vein,  leads  to  serious  and  even  fatal  hemorrhage  if  untreated. 

Accompanying  the  attack  of  infection  there  are  frequently  phlebitis  and 
periphlebitis  of  the  enlarged  veins,  with  the  signs  and  symptoms  already  de- 
scribed under  Phlebitis.  The  inflammation  of  the  veins  may  cause  their  oblit- 
eration or  the  formation  of  abscesses,  but  is  rarely  attended  with  more  serious 
results.  In  comparatively  rare  cases  epithelioma  may  develop  upon  the  base 
of  one  of  these  chronic  ulcers  of  the  leg. 


Fig.   129. — Varicose  Veins  of  the  Leg. 


CHAPTER    XI 
THE   X-RAYS   IN   SURGICAL   DIAGNOSIS 

The  use  of  the  X-rays  in  surgical  diagnosis  may  be  properly  considered 
under  several  heads : 

I.  The  X-ray  apparatus.  II.  Technique:  (a)  The  fluoroscope;  (b)  the 
making  of  X-ray  pictures  and  the  development  of  the  photographic  plate;  (c) 
stereoscopic  radiography.  III.  Diagnostic  value  of  the  X-rays  in  injuries  and 
diseases:  (a)  Fractures,  dislocations,  and  deformities  of  bone;  (b)  in  diseases 
of  bones;  (c)  in  the  detection  and  localization  of  foreign  bodies;  (d)  in  the 
recognition  of  tumors  and  diseases  of  the  soft  parts;  (e)  in  the  detection  of 
pathological  concretions  (stone  in  the  kidney,  ureter,  the  urinary  bladder)  and 
the  detection  of  biliary  calculi;  (/)  the  injuries  produced  by  the  diagnostic 
use  of  the  X-rays  upon  patients  and  upon  X-ray  operators. 

I.  THE    X-RAY    APPARATUS 

Current 

With  the  static  machine  no  outside  source  of  electricity  is  required,  but 
the  street  current  is  a  very  convenient  source  of  power.  For  induction  coils 
the  street  current  of  110  volts  is  the  most  convenient  and  efficient  source. 
Batteries,  either  primary  or  storage,  may  be  used,  but  are  generally  less  effi- 
cient. To  operate  large  coils  efficiently  the  original  cost  and  expense  of  main- 
tenance of  such  batteries  would  be  very  great.  The  alternating  currents  may 
be  used  with  the  Wehnelt  electrolytic  interrupter  on  an  ordinary  coil ;  it  is 
said,  however,  to  be  more  destructive  to  the  interrupter  than  is  the  direct 
current.  The  several  forms  of  apparatus  designed  to  be  used  with  the  alter- 
nating current  of  high  voltage  are  said  to  be  less  satisfactory  than  ordinary 
induction  coils. 

Apparatus 

In  order  to  excite  X-ray  tubes  for  the  production  of  X-rays  we  may  use 
a  static  electric  machine  or  an  induction  coil. 

Static  Machines. — Static  electric  machines  are  believed  by  certain  operators 

to  possess  practical  advantages  over  induction  coils.     Formerly  it  was  believed 

that  X-ray  burns  were  less  likely  to  be  produced  by  tubes  excited  by  the  static 

339 


340  THE   X-RAYS    IN    SURGICAL   DIAGNOSIS 

machine;  recent  experience,  however,  has  shown  that  this  belief  was  not  well 
founded ;  some  of  the  most  serious  burns  have  been  caused  by  static  machines. 

Those  who  prefer  static  machines  allege:  (1)  That  the  discharge  contains 
a  smaller  total  of  energy ;  hence  there  is  less  heating  effect  upon  the  electrodes 
of  the  tube,  and  that,  in  consequence,  the  electrical  resistance  of  the  tube,  or 
its  vacuum,  as  it  is  sometimes  called,  is  maintained  at  a  constant  quantity 
during  the  passage  of  the  current  with  less  difficulty,  and  the  tubes  last  longer ; 
these  statements  are  no  doubt  true.  (2)  There  is  greater  steadiness  in  the 
production  of  the  rays,  and  consequently  the  image  thrown  upon  the  fluores- 
cent screen  is  clearer  and  sharper;  this  is  in  general  correct.  (3)  Without 
practical  experience  with  static  machines,  I  should  suppose  that  the  necessary 
time  of  exposure  for  the  production  of  radiographs  might  be  more  constant  for 
a  given  density  of  object  to  be  penetrated  than  is  the  case  with  tubes  excited 
by  means  of  a  coil.  (4)  The  machine  can  be  operated  without  any  extraneous 
source  of  electricity. 

The  disadvantages  of  static  machines  are:  (1)  The  greater  original  cost  of 
the  apparatus,  the  necessarily  greater  size  and  weight  and  absence  of  portabil- 
ity. (2)  Uncertainty  of  action  in  damp  weather  unless  special  precautions  are 
used  which  sometimes  involve  a  delay  of  several  hours.  (3)  On  account  of 
insufficient  energy,  except  in  cases  of  the  very  largest  static  machines,  there 
appears  to  be  inability  to  produce  good  pictures  of  the  hip-joint,  pelvis,  and 
spine  of  large  adults  except  after  rather  long  exposures. 

Induction  Coils. — The  advantages  of  induction  coils  over  static  machines 
are:  (1)  They  are  less  expensive.  (2)  They  may  be  made  of  small  size  and 
great  efficiency.  (3)  They  may  be  made  portable.  (4)  They  are  not  affected 
by  atmospheric  conditions.  (5)  They  may  be  made  to  produce  a  larger  amount 
of  energy  than  can  be  used  with  any  tube  hitherto  constructed,  and  hence 
shorter  exposures  are  sufficient.  (6)  The  densest  structures  may  be  penetrated 
in  a  reasonable  time  with  satisfactory  results. 

A  coil  of  large  size,  or  at  least  one  giving  a  very  heavy  secondary  discharge 
— what  is  commonly  spoken  of  as  a  thick  blue  spark — and  a  coil  of  the  best 
obtainable  construction  is  required  for  satisfactory  work.  Good  radiographs 
are  hard  enough  to  obtain  with  any  apparatus ;  with  an  inferior  one  the  diffi- 
culties are  greatly  increased.  The  more  powerful  the  coil  and  the  heavier  its 
discharge  the  greater  the  quantity  of  electrical  energy  which  may  be  made  to 
pass  through  an  X-ray  tube  in  a  given  time,  and  the  greater  the  photographic 
effect — other  things  being  equal — of  the  rays  produced  by  such  a  tube,  hence 
the  shorter  the  exposure  necessary  to  produce  a  good  negative.  Moreover,  a  tube 
giving  off  photographically  powerful  rays  need  not  be  placed  very  near  the  pa- 
tient's skin  in  order  to  penetrate  the  thicker  portions  of  the  body ;  the  distortion 
in  the  negative  is  thereby  diminished,  and*  X-ray  burns  are  less  apt  to  occur. 
At  the  present  time  there  are  upon  the  market  in  America  coils  of  a  number  of 
manufacturers  of  very  perfect  construction.  Recent  improvements  make  it 
possible  to  construct  comparatively  small  and  light  coils  of  great  efficiency ;  and 


THE   X-KAY   APPAKATUS  341 

while  coils  capable  of  producing  a  spark  in  air  eighteen  inches  in  length  are  very 
commonly  used,  vet  it  is  probable  that  a  coil  giving  a  thick  ribbonlike  discharge 
ten  or  twelve  inches  long  answers  every  practical  requirement  equally  well. 

Interrupters. — Quite  as  important  as  the  coil  is  the  character  of  the  device 
used  to  cause  interruptions  in  the  primary  circuit.  The  more  complete  and 
sudden  these  interruptions  can  be  made  the  better,  and,  within  certain  limits, 
the  greater  the  rapidity  of  these  interruptions  the  heavier  the  discharge  from 
the  secondary  coil  in  a  given  time  and  the  shorter  time  necessary  to  take  an 
X-ray  picture  through  a  mass  of  tissue  of  a  given  density.  The  number  of 
devices  which  have  been  used  for  interrupting  the  primary  current  is  large; 
they  are  nearly  all  so  expensive  as  to  increase  considerably  the  cost  of  an 
X-ray  outfit.  Some  of  them  are  very  efficient,  some  are  less  so,  and  many  of 
them  require  a  good  deal  of  attention  to  keep  them  in  order.  That  mechanical 
interrupter  which  interrupts  the  primary  current  by  means  of  a  vibrating  steel 
spring  alternately  attracted  to  and  released  from  the  core  of  the  main  coil,  or 
of  a  smaller  coil,  placed  in  the  primary  circuit  is  simple,  fairly  durable,  rather 
noisy,  and  only  efficient  when  used  with  coils  of  moderate  size  and  for  the 
production  of  a  secondary  discharge  of  only  moderate  quantity.  It  is  in  my 
experience  less  efficient  than  some  of  the  other  forms  when  a  heavy  secondary  dis- 
charge is  desired.  Nearly  all  the  mechanical  interrupters  require  a  condenser  in 
the  primary  circuit.  The  mechanical  break-wheel  interrupter  is  efficient  but 
very  noisy.  The  mercury-jet  interrupter  is  clean,  not  noisy,  but  scarcely  per- 
mits the  production  of  as  heavy  a  secondary  discharge  as  is  sometimes  desirable. 

The  electrolytic  interrupter  of  Wehnelt,  or  some  modification  of  it,  is  in 
very  general  use  at  the  present  time,  and  although  certain  troubles  and  disad- 
vantages attend  its  use,  these  are  more  than  compensated  for  by  the  advantages 
about  to  be  described.  It  is  now7  made  in  many  forms.  It  may  be  constructed 
in  a  simple  form  by  any  one  possessing  the  slightest  mechanical  aptitude,  at 
a  cost  of  five  dollars  at  the  most.  No  condenser  is  required,  and  while  the 
apparatus  is  best  suited  to  the  use  of  the  direct  current,  the  alternating  cur- 
rent may  be  used  with  some  slight  difficulty,  since  the  device  permits  the  pas- 
sage of  a  current  in  only  one  direction.  When  used  with  a  coil  of  suitable 
construction,  the  efficiency  of  the  apparatus  is  very  greatly  increased ;  for  exam- 
ple, when  using  this  interrupter  one  may  take  a  good  picture  of  the  adult 
elbow  in  a  second,  whereas  with  a  very  good  mechanical  interrupter,  on 
the  same  coil  and  with  a  similar  tube,  several  minutes  may  be  required  to 
produce  the  same  result.  Inasmuch  as  this  chapter  may  be  read  by  some  one 
anxious  to  try  this  device,  but  unfamiliar  with  its  construction  and  unwilling 
to  go  to  the  expense  of  its  purchase  in  a  finished  form,  a  short  description  of  a 
simple  form  of  it  is  here  given,  together  with  the  method  of  its  use. 

Principles  and  Construction  of  the  Wehnelt  Interrupter. — The  action  de- 
pends upon  the  following  facts:  If  a  plate  of  lead  and  a  piece  of  platinum 
wire,  the  latter  insulated  except  for  a  small  portion  at  one  end,  are  immersed 
in  a  vessel  containing  dilute  sulphuric  acid  of  a  specific  gravity  of  20°-25Q 


342  THE   X-EAYS   IN   SUKGICAL  DIAGNOSIS 

Beaume,  and  a  current  of  electricity  is  passed  through  the  acid  by  attaching 
the  positive  pole  of  the  source  of  current  to  the  platinum  and  the  negative  to 
the  lead,  and  if  the  tension  of  the  current  is  considerable  (best  80  volts  or 
more),  electrolysis  of  the  water  takes  place  with  the  disengagement  of  gas  at 
either  pole.  If  the  platinum  point  projecting  into  the  acid  is  of  the  proper 
size  the  bubbles  of  gas  forming  about  it  cause  a  very  sudden  break  in  the  cur- 
rent, and  as  each  bubble  of  gas  leaves  the  platinum  or  is  destroyed,  the  current 
is  reestablished,  a  new  bubble  is  formed,  and  the  current  is  again  broken.  This 
phenomenon  repeats  itself  with  a  rapidity  which  varies  directly  as  the  strength 
of  the  current  and  inversely  as  the  area  of  platinum  exposed  in  the  acid.  The 
interruptions  in  the  primary  current  occur  many  thousands  of  times  a  minute. 
With  a  small,  area  of  platinum  and  a  powerful  current  they  may  be  made  to 
occur  some  hundreds  of  times  a  second.  These  interruptions,  so  sudden,  so 
complete,  so  rapid,  greatly  increase  the  energy  of  the  secondary  discharge,  and 
excite  in  X-ray  tubes  rays  of  great  power.  A  simple  form  of  the  apparatus 
may  be  constructed  as  follows:  Any  one  of  the  ordinary  types  of  glass  battery 
jars,  best  of  a  capacity  of  several  quarts  and  of  a  depth  of  eight  inches  or  more, 
may  be  used  as  a  receptacle  for  the  acid.  Upon  one  side  of  the  jar  there  is 
suspended  in  the  acid  a  plate  of  lead  having  a  superficial  area  of  eight  inches 
or  more,  in  electrical  contact  with  a  binding  post,  for  attaching  to  the  nega- 
tive pole.  The  arrangement  of  the  platinum  electrode  may  be  as  follows: 
A  piece  of  copper  wire,  a  foot  or  more  in  length,  size  14,  is  annealed  by 
heating  in  the  flame  of  a  Bunsen  burner  for  a  distance  of  an  inch  and  a  half 
on  one  end.  The  annealed  portion  is  hammered  flat  into  a  tape.  After  ham- 
mering, it  is  again  annealed.  A  piece  of  platinum  wire  (best  containing  a 
little  iridium),  an  inch  or  more  in  length,  size  No.  16  to  14,  is  tightly  wound 
with  the  tapelike  end  of  the  copper  wire  for  a  distance  of  half  an  inch  from 
one  end.  A  piece  of  ordinary  lead-glass  tubing,  one  third  of  an  inch  outside 
diameter,  serves  fairly  well  as  an  insulator.  The  platinum  and  copper  wire 
are  inserted  into  a  piece  of  this  tubing,  about  a  foot  in  length,  until  the  point 
of  the  platinum  is  just  even  with  the  orifice  of  the  farther  end  of  the  tube. 
It  is  convenient  to  thread  the  copper  wire  upon  two  little  disks  of  cork,  with 
notches  cut  out  from  one  side  of  each,  and  of  such  size  as  will  pass  easily 
into  the  caliber  of  the  glass  tube.  The  platinum  wire  can  thus  be  properly 
centered  in  the  orifice  at  the  end  of  the  tube.  The  edge  of  glass  tube  surround- 
ing the  platinum  point  is  then  neatly  fused  in  the  blowpipe  flame  until  the 
tube  is  closed  at  that  end,  leaving  from  2  to  4  mm.  of  platinum  point  project- 
ing from  the  end  of  the  tube,  which  should  have  a  shape  not  unlike  the  apex 
of  a  steel- jacketed  military  rifle  bullet.  If  lead-glass  tubing  is  used,  and  the 
fusing  is  carefully  done,  and  the  glass  is  allowed  to  cool  slowly,  the  insulation 
will  last  for  a  number  of  weeks,  daily  use,  and  ten  minutes'  work  serves  for  its 
replacement  in  case  of  breakage,  at  the  cost  of  a  penny  or  two.  Should  an 
adjustable  electrode  be  desired,  one  of  the  small  lava  tips  with  a  single  round 
perforation,  such  as  are  used  in  certain  gas  engines,  and  which  can  be  pur- 


THE    X-EAY   APPARATUS  343 

chased  for  thirty-six  cents  a  dozen,  may  be  fused  into  the  end  of  a  glass  tube, 
and  the  platinum  electrode,  which  must  accurately  fit  the  hole  in  the  lava  tip, 
may  lie  made  to  project  to  any  desired  extent  through  this  orifice.  To  pre- 
vent the  acid  from  running  up  into  the  interior  of  the  glass  tube,  a  little  melted 
vaselin  may  be  poured  into  the  top  of  the  tube  and  allowed  to  fill  the  space 
between  the  platinum  wire  and  the  lava.  The  hole  in  the  lava  tip  may  be 
enlarged  to  any  desired  size  by  means  of  a  fine  rat-tail  file  dipped  in  turpentine. 
A  more  durable  and  ornate  apparatus  may  be  made  out  of  a  piece  of  hard- 
rubber  tubing,  into  the  bore  of  which  a  brass  rod  is  accurately  fitted.  Upon 
one  end  of  the  brass  rod  is  brazed  a  piece  of  platinum  wire,  size  14  or  16,  and 
upon  the  other  there  is  a  binding  post,  and  beneath  it  a  movable  screw  nut  with 
a  milled  head.  A  screw  thread  is  cut  in  the  interior  of  the  lower  end  of  the 
rubber  tube,  and  into  it  is  screwed  a  lava  tip,  perforated  to  admit  tightly  the 
platinum  wire.  The  platinum  electrode  thus  becomes  adjustable.  This  arrange- 
ment is  a  device  of  Dr.  R.  H.  Cunningham,  of  this  city.  The  lava  tips  are  made 
of  any  desired  size  or  shape  by  D.  M.  Stuard,  of  Chattanooga,  Tenn.  It  is 
desirable  that  the  lava  tips  should  be  more  or  less  conical  in  shape,  at  the  point 
which  projects  into  the  acid,  and  through  which  the  platinum  wire  protrudes; 
if  flattened,  bubbles  of  gas  will  occasionally  accumulate  about  the  platinum 
point,  and  the  interrupter  will  cease  to  operate. 

The  containing  vessel  should  be  of  considerable  size ;  otherwise  the  acid 
will  become  hot,  and  the  interruptions  will  not  take  place.  With  a  jar  con- 
taining about  1,500  c.c.  of  acid,  no  heating  sufficient  to  interfere  with  the 
running  of  the  apparatus  has  occurred  in  my  experience  after  half  an  hour 
of  continuous  use.  If  it  is  desired  to  use  the  interrupter  continuously  for  some 
time,  a  second  jar  of  acid  may  be  kept  in  readiness,  and  the  electrodes  may 
be  transferred  to  it,  when  the  acid  in  the  first  jar  becomes  hot. 

If  the  error  is  made  of  attaching  the  negative  pole  to  the  platinum  electrode 
and  the  positive  to  the  lead,  the  platinum  wire  will  be  fused. 

The  positive  and  the  negative  poles  may  easily  be  distinguished  by  holding 
them  separated  in  a  glass  of  water.  The  pole  from  which  the  greater  quan- 
tity of  gas  escapes  is  the  negative  pole.  The  interrupter,  the  rheostat,  and  the 
switch  for  turning  off  and  on  the  current  are  arranged  in  series  in  the  primary 
circuit  of  the  coil.  One  of  the  greatest  advantages  of  the  apparatus  is  the 
ease  with  which  the  amount  of  energy  of  the  secondary  discharge  can  be  regu- 
lated to  suit  the  capacity  of  any  X-ray  tube.  With  a  small  amount  of  platinum 
protruding  into  the  acid  the  interruptions  occur  very  rapidly;  but  the  total 
energy  is  small,  and  if  considerable  resistance  is  thrown  into  the  circuit  by 
means  of  a  rheostat,  a  lightly  built  tube  may  be  made  to  do  its  best  without 
undue  heating  effects.  If,  on  the  other  hand,  the  platinum  is  protruded  to  a 
considerable  extent  and  but  little  resistance  is  left  in  the  circuit,  the  inter- 
ruptions are  less  rapid ;  but  the  amount  of  energy  produced  is  greater  than 
the  heaviest  tube  can  endure  for  more  than  a  very  short  time. 

It  is  stated  by  makers  of  coils  that  this  interrupter  tests  the  efficiency  of 


344  THE   X-EAYS   IN   SUEGICAL   DIAGNOSIS 

the  insulation  of  the  coil  itself  much  more  severely  than  any  other.  A  thor- 
oughly well-made  coil  is  therefore  indispensable.  As  a  protection  against  an 
accident  so  serious  as  a  perforation  of  the  insulation  of  the  coil,  I  am  in  the 
habit  of  setting  the  parallel  spark-gap  of  my  coil  at  a  distance  at  least  several 
inches  less  than  the  maximum  separation.  I  may  add  that  this  interrupter 
requires  no  care  beyond  the  addition  of  water  and  acid  now  and  then,  and  at 
long  intervals  the  removal  of  the  brass  rod  and  the  injection  of  a  small  quan- 
tity of  vaselin  into  the  caliber  of  the  hard-rubber  tube.  This  affords  protection 
against  the  ascent  of  the  acid  into  the  interior  in  case  the  platinum  wire  does 
not  fit  accurately  into  the  bore  of  the  lava  tip. 

If  the  lava  tip  becomes  damaged  in  time,  it  may  be  replaced  in  a  moment 
at  a  cost  of  eight  cents.  It  is  well  to  paint  the  junction  of  the  lava  and  hard 
rubber  with  a  solution  of  asphalt  and  chloroform. 

The  Caldwell  Interrupter. — I  have  also  used  an  electrolytic  interrupter 
made  by  Wappler  Brothers  of  this  city. 

The  principle  of  its  construction  was  discovered  by  Mr.  Caldwell,  of  New 
York,  and  the  instrument  is  a  modification  of  the  Caldwell  interrupter.  Its 
construction  is  as  follows:  A  glass-battery  jar  containing  dilute  sulphuric  acid 
holds  two  lead  electrodes;  one  of  these  electrodes  is  contained  within  and  the 
other  surrounds  a  porcelain  cup.  In  the  wall  of  the  porcelain  cup,  below  the 
level  of  the  acid,  are  bored  several  minute  holes,  which  serve  in  some  sort 
for  the  transmission  and  interruption  of  the  current.  The  rapidity  of  the 
interruptions  produced  is  very  great,  and  varies  directly  with  the  quantity 
of  the  current.  The  amount  of  energy  produced  in  the  secondary  discharge 
appears  to  depend  upon  the  number  of  holes  in  the  porcelain.  The  holes  may 
be  one  sixty-fourth  of  an  inch  in  diameter.  I  have  not  been  able  with  this 
interrupter  to  get  a  sufficiently  heavy  discharge  to  operate  large  tubes  to  the 
best  advantage.  This  interrupter  has  the  advantage  of  being  very  simple;  it 
requires  no  care  and  is  almost  noiseless. 

Since  the  preceding  portion  of  this  chapter  was  first  written,  several  years 
ago,  a  number  of  modifications  of  the  Wehnelt  interrupter  have  been  devised. 
Porcelain  is  now  very  generally  used  instead  of  lava,  and  a  long  porcelain 
tube  is  substituted  for  the  combination  of  hard  rubber  and  lava.  The  inter- 
rupter has  also  been  combined  with  a  mechanical  device  whereby,  through 
the  action  of  a  small  electric  motor,  the  anode  is  made  to  plunge  rapidly  in  and 
out  of  the  acid.  It  is  questionable  whether  any  of  the  more  radical  modifica- 
tions are  improvements. 

Tubes. — The  most  recent  experiences  of  those  interested  in  X-rays  through- 
out the  world  point  conclusively  to  the  advantage  gained  by  the  use  of  X-ray 
tubes  which  permit  the  passage  through  them  of  a  very  large  amount  of  elec- 
trical energy.  It  is  quite  true  that  with  a  very  rapid  series  of  impulses  at 
high  tension  much  may  be  accomplished  with  a  current  of  very  small  amperage ; 
but  to  obtain  satisfactory  pictures  of  the  thicker  parts  of  the  body  in  a  short 
time  the  amount  of  energy  passing  through  the  tube  must  be  considerable, 


THE   X-RAY   APPARATUS  345 

and  to  this  end  tubes  of  large  size  and  of  rather  elaborate  and  expensive  con- 
struction are  required.  This  necessity  depends  upon  the  following  facts:  The 
photographic  effect  of  X-rays  and  their  power  to  penetrate  dense  structures 
vary  within  limits  directly  with  the  quantity  and  intensity  of  the  current,  and 
with  the  number  of  interruptions  or  impulses  passing  in  a  given  time.  The 
efficiency  and  character  of  the  rays  depend  also  upon  the  degree  of  rarefaction 
or  vacuum  within  the  tube;  and,  since  a  higher  vacuum  in  the  tube  means 
also  a  higher  resistance  to  the  passage  of  the  electrical  current,  the  equivalent 
of  this  resistance  measured  by  the  length  of  a  parallel  spark-gap  in  air  becomes 
a  valuable  index  of  the  character  of  the  rays  which  are  emitted  from  a  tube, 
the  resistance  of  which,  under  varying  conditions,  has  been  learned  by  trial. 
But  the  degree  of  rarefaction  and  resistance  of  a  tube  varies  as  the  result  of 
the  passage  of  an  electrical  current  of  high  potential  through  it  in  two  ways. 

If  enough  current  is  passing  to  render  the  surface  of  the  platinum  anode 
red  hot,  it  happens  with  many  tubes,  though  not  with  all,  that  the  resistance 
of  the  tube  to  the  passage  of  the  current,  as  well  as  the  degree  of  rarefaction, 
is  suddenly  lowered.  In  this  condition  the  X-rays  produced  have  a  lower 
penetrative  power,  and  if  the  tube  is  kept  running  in  this  state  for  a  short 
time  it  may  become  temporarily  useless  for  photographic  purposes. 

If,  on  the  other  hand,  such  a  tube  is  allowed  to  cool,  it  will  usually  be 
found  that  its  vacuum  has  been  raised  to  a  higher  degree  than  before  it  was 
heated.  The  resistance  of  the  tube  to  the  passage  of  the  current  has  been 
increased,  and  the  rays  given  off  from  such  a  tube  possess  a  greater  power 
of  penetration.  The  longer  the  tube  is  used,  the  more  marked  does  this  change 
become,  until,  in  spite  of  various  temporary  remedial  agents,  no  current  can 
be  made  to  illuminate  it.  If  the  effort  is  persisted  in,  the  electric  sparks 
may  pass  around  the  whole  length  of  the  tube,  or,  what  is  unfortunately  more 
common,  they  will  perforate  the  tube,  allowing  the  entrance  of  air,  thus  de- 
stroying the  vacuum,  and  therefore  the  usefulness  of  the  tube. 

It  will  thus  be  seen  that  any  device  that  enables  the  operator  to  reduce  the 
vacuum  in  a  tube  which  has  become  "  hard,"  as  it  is  called,  greatly  prolongs 
the  useful  life  of  the  tube. 

But,  aside  from  the  question  of  expense  involved,  the  far  more  important 
consideration  must  be  noted  that  with  a  tube  the  vacuum  of  which  is  con- 
stantly changing  both  during  and  out  of  use,  and  hence  also  the  penetrative 
power  of  its  rays,  the  operator  using  it  will  have  great  difficulty  in  producing 
uniform  results.  He  will  be  unable  accurately  to  judge  how  long  an  exposure 
will  be  necessary  to  produce  good  radiographs  of  objects  having  the  same  density 
upon  different  occasions.  The  object  of  radiography  is,  in  general,  to  produce 
shadow  pictures  which,  while  showing  detailed  shadows  of  the  densest  struc- 
tures, such  as  bones,  foreign  bodies  composed  of  metal  and  the  like,  will  also 
show  the  shadows  of  less  dense  structures,  such  as  calculi  in  the  kidney,  gall- 
bladder, ureter,  and  elsewhere,  and  of  organs,  muscles,  tendons,  and  other  soft 
tissues.     In  order  to  make  such  radiographs,  it  is  necessary  to  use  a  tube  of 


346  THE   X-RAYS   IN   SURGICAL   DIAGNOSIS 

such  penetrative  power  or  vacuum  as  will  represent  upon  a  photographic  plate 
comparatively  slight  differences  of  density,  and,  briefly,  it  may  be  stated  that 
the  majority  of  radiographers  agree  that  a  tube  that  answers  these  require- 
ments best  is  one  of  comparatively  low  vacuum,  but  which  will  permit  the  con- 
tinuous passage  through  it  of  a  large  amount  of  electrical  energy  without  a 
still  further  fall  of  its  vacuum.  From  what  has  already  been  written  in  expla- 
nation, it  is  easy  to  understand  that  a  tube  that  can  be  run  for  a  long  time  with 
a  heavy  current  without  much  change  of  vacuum  up  or  down,  and  one  which 
possesses  some  device  for  bringing  down  the  vacuum  to  any  desired  extent 
after  it  has  become  too  high,  must  be  very  valuable  and  greatly  to  be  desired. 
I  wish  to  emphasize  my  remarks  in  regard  to  this  essential  quality  in  a  good 
tube.  The  necessity  has  already  been  dwelt  upon  by  Dr.  C.  L.  Leonard  of 
Philadelphia,  and  others;  and  yet  I  am  led  to  think  that  its  full  significance 
is  not  appreciated  by  everyone  who  takes  radiographs.  An  ideal  X-ray  tube 
would  be  one  permitting  the  use  of  a  heavy  current,  a  great  rapidity  of  inter- 
ruption, while  maintaining  a  constant  vacuum.  The  best  modern  tubes  are 
constructed  with  a  view  to  obtain  these  qualities ;  in  some  of  them  one  qual- 
ity has  been  gained  while  others  are  lacking,  and,  as  far  as  I  am  aware,  no 
tube  has  been  devised  which  combines  them  all  in  a  satisfactory  degree.  There 
are  several  types  of  tubes  which  fulfill  the  conditions  fairly  well.  Among 
them  are  the  Queen  self-adjusting  tube,  the  tube  of  E.  Gundelach,  of  Berlin, 
and  the  tube  of  Dr.  E.  Griinmach;  they  are  all  obtainable  in  New  York. 

1.  The  Queen  Tube. — The  Queen  tube  depends  for  the  constancy  of  its 
vacuum  upon  a  most  ingenious  device.  A  small  secondary  tube  is  attached 
to  the  main  tube.  The  vacuum  of  the  latter  is  very  high.  When  the  current 
is  turned  on,  the  resistance  of  this  vacuum  is  so  great  that  the  electricity  is 
forced  to  pass  through  the  smaller  tube,  the  resistance  of  which  is  less.  In 
so  doing  a  small  platinum  anticathode  is  heated,  and  this  heat  drives  off  a  small 
quantity  of  watery  vapor  from  a  hygroscopic  salt  in  communication  with  the 
main  tube,  thus  lowering  its  vacuum  and  resistance.  The  current  passes 
through  the  smaller  tube  until  the  resistance  of  the  two  circuits  is  equal,  when 
it  passes  through  the  main  tube,  causing  the  production  of  X-rays. 

The  resistance  through  the  circuit  of  which  the  smaller  tube  forms  a  part 
is  adjustable  by  means  of  a  spark-gap,  and  the  extent  of  this  gap  is  thus  a 
measure  of  the  resistance  of  the  circuit.  The  main  tube  having  become  illumi- 
nated, the  current  ceases  to  pass  through  the  smaller  tube  and  across  the  spark 
gap,  the  hygroscopic  salt  cools,  reabsorbs  the  watery  vapor  from  the  main  tube, 
increasing  the  resistance,  when  the  current  passes  again  by  the  other  circuit. 

This  process  is  repeated  indefinitely,  thereby  keeping  the  main  tube  at  a 
constant  vacuum,  and  furnishing  thereby  X-rays  of  the  same  penetrative  power 
as  long  as  the  spark-gap  remains  the  same.  The  principle,  construction,  and 
operation  of  these  tubes  are  admirable,  but  as  yet  they  have  not  been  made 
upon  a  sufficiently  large  and  heavy  model  to  permit  the  use  of  enough  energy 
to  make  good  radiographs  of  the  trunk  and  hip-joints  of  large  individuals  in  a 


THE   X-KAY   APPAEATUS  347 

reasonable  time.  My  best  radiographs  of  parts  thinner  than  the  hip  have  been 
made  with  these  tubes,  but  they  have  repeatedly  failed  in  my  hands  to  produce 
good  negatives  of  the  pelvis,  spine,  and  hips  of  large  subjects.  The  platinum 
anticathode  is  not  heavy  enough  to  endure  the  prolonged  use  of  enough  energy 
for  the  purpose.  If  the  automatic  attachment  for  the  regulation  of  the  vacuum 
could  be  united  with  some  efficient  cooling  device,  the  combination  would  leave 
little  to  be  desired.  Since  the  above  was  written,  this  advantage  has  been 
obtained. 

2.  The  Tube  of  E.  Gundelach. — The  tube  of  E.  Gundelach,  of  Berlin,  pos- 
sesses no  special  device  for  maintaining  a  constant  vacuum,  but  operating  indi- 
rectly toward  this  end  the  anticathode  is  massive,  and  the  heavy  piece  of  metal 
of  which  it  consists  is  seated  upon  a  hollow  metallic  cylinder,  about  six  inches  in 
length.  Much  of  the  heat  produced  upon  the  surface  of  the  anticathode  is  thus 
dissipated,  and  the  tube  permits  the  use  of  a  large  amount  of  energy  continu- 
ously for  several  minutes  without  much  fall  of  vacuum.  It  suffers,  however, 
after  the  passage  of  a  heavy  current  for  three  or  four  minutes,  and  does  not 
recover  itself  until  completely  cool,  and  after  continuous  use  the  vacuum  rises 
after  cooling  to  a  degree  which  renders  the  tube  entirely  unfit  for  the  production 
of  good  pictures. 

To  overcome  this  difficulty,  the  tube  is  provided  with  a  regenerative  appa- 
ratus, so  called.  This  consists  of  a  small  side  tube,  into  which  is  fused  what 
appears  to  be  a  piece  of  platinum  wire.  One  end  of  the  wire  projects  into  the 
interior  of  the  tube,  the  other  into  the  air.  If  this  wire  is  heated  for  some 
seconds  in  the  flame  of  an  alcohol  lamp  the  vacuum  of  the  tube  falls.  This 
heating  must  be  cautiously  performed,  or  the  vacuum  may  be  reduced  too  far. 
The  lowering  of  the  vacuum  is  said  to  depend  upon  the  escape  of  hydrogen  gas, 
which  has  been  occluded  in  the  wire  and  is  driven  off  by  heat.  The  metal  in 
the  interior  of  the  tube  is  coated  with  an  enamel  which  is  supposed  to  prevent 
the  purple  cloud  which  forms  upon  the  interior  of  X-ray  tubes  after  they  have 
been  used  for  some  time. 

I  have  used  these  tubes  for  radiographs  of  the  more  difficult  kind  with  good 
results,  but  I  have  not  found  the  regenerative  apparatus  easy  to  control.  This 
tube  is  now  (1909)  considered  the  best  obtainable  tube. 

3.  The  Tube  of  Dr.  E.  Griinmach. — The  tube  of  Dr.  E.  Griinmach  has  a 
device  intended  to  prevent  the  heating  of  the  anticathode  and  a  device  for 
lowering  the  vacuum  when  it  has  reached  a  high  point.  The  device  for  pre- 
venting the  heating  effect  of  the  current  is  very  efficient.  The  anticathode  of 
platinum  is  supported  by  a  metal  cylinder  of  aluminum.  Within  this  cylinder 
is  another  made  of  lead,  closed  at  the  end  in  contact  with  the  platinum.  The 
other  end  is  in  communication  with  the  outside  air,  and  into  the  aperture  is 
thrust  a  perforated  cork,  holding  two  small  metal  tubes,  which  serve  to  permit 
the  circulation  of  a  current  of  cold  water,  which  carries  off  very  rapidly  the 
heat  generated  by  the  bombardment  of  the  anticathode.  The  cold  water  is 
readily  supplied  from  the  house  tap  through  the  medium  of  a  small  rubber  pipe. 


348  THE   X-EAYS   IN   SUEGICAL  DIAGNOSIS 

Another  pipe  carries  the  waste  into  the  sink.  The  device  for  lowering  the 
vacuum  consists  of  a  small  side  bulb,  containing  a  salt  which  gives  off  water 
when  heated. 

By  careful  heating  with  a  lighted  match,  the  vacuum  may  be  reduced  grad- 
ually to  any  desired  point. 

This  cold-water  tube,  as  it  may  be  called,  permits  the  use  continuously, 
without  notable  change  in  the  quality  of  the  rays  given  off,  of  a  far  larger 
amount  of  energy  than  is  the  case  with  any  other  tube  that  I  have  seen. 

The  photographic  effect  through  the  densest  structures  is  also  accomplished 
in  a  satisfactory  way  in  a  short  time.  When  using  a  large  amount  of  energy 
for  more  than  three  minutes,  the  anticathode  does  become  heated  to  a  dull-red 
heat  in  spite  of  the  cold  water,  but  the  vacuum  does  not  appear  to  fall  to  a 
serious  extent  even  when  the  tube  is  kept  running  in  this  heated  condition. 

If  the  current  is  stopped,  the  vacuum  promptly  rises  nearly  to  the  origi- 
nal point. 

For  heavy  work  this  tube  is,  in  my  opinion,  incomparably  the  best  with 
which  I  am  acquainted. 

Since  the  above  was  written  numerous  changes  and  some  improvements 
have  been  made  in  the  construction  of  X-ray  tubes;  they  consist  in  cooling 
devices ;  in  devices  for  keeping  the  electrical  resistance  of  the  tube  constant 
automatically  while  the  tiibe  is  in  use ;  and  in  the  construction  of  tubes  capable 
of  enduring  a  very  heavy  discharge  without  material  change  in  the  vacuum  and 
of  devices  intended  to  prevent  the  passage  of  the  current  through  the  tube  in 
the  wrong  direction.  A  description  of  these  devices  may  be  found  in  the  cata- 
logues of  the  makers  of  X-ray  apparatus.  There  are  also  used  multiple  spark- 
gaps  in  series  with  one  or  both  of  the  electrodes  of  the  tube  in  the  secondary 
circuit,  they  are  very  useful  aids  in  rendering  the  secondary  discharge  of  the 
coil  of  a  suitable  intensity,  such  that  X-rays  of  the  desired  penetrative  power 
may  be  produced  at  will. 

II.    TECHMC 

The  General  Technic  of  Radiography 

The  strictest  attention  to  details,  from  first  to  last,  is  necessary  in  order  to 
produce  uniformly  good  results.  The  operator  must,  of  course,  become  thor- 
oughly familiar  with  every  part  of  the  apparatus  under  varying  conditions. 
This  is  particularly  the  case  with  regard  to  X-ray  tubes,  and  he  who  purchases 
two  or  three  of  the  best  tubes  obtainable  learns  to  know  for  what  purposes 
each  one  is  best  suited,  and  guards  them  with  care  from  accidental  injury, 
will  soon  learn  to  know,  from  the  mere  appearance  of  the  tube,  while  illumi- 
nated, what  sort  of  a  result  is  likely  to  be  produced  in  the  way  of  a  picture 
in  a  given  time.  Several  important  mechanical  details  must  be  studied,  and, 
as  far  as  possible,  the  relation  of  the  tube  to  the  plate  and  to  the  part  to  be 
pictured  should  be  reduced  to  some  definite  system.     It  will  be  remembered 


TECHXIC  349 

that,  as  far  as  is  known,  the  X-ray  may  be  assumed  to  proceed  from  the  center 
of  the  platinum  anticathode  in  straight  lines  in  all  directions  from  a  point 
or  focus  upon  its  surface.  There  follows  the  well-known  rule,  also  applicable 
to  ordinary  light  rays,  that  the  intensity  of  the  illumination  of  an  object 
varies  inversely  as  the  square  of  its  distance  from  the  source  of  light.  When 
applied  to  radiography,  this  physical  fact  is  important  to  bear  in  mind — e.  g., 
if  a  good  radiograph  of  a  given  part  can  be  obtained  at  a  distance  of,  say,  twelve 
inches  in  one  minute,  at  a  distance  of  twenty-four  inches,  an  exposure  of  four 
minutes  will  be  required  to  produce  the  same  result.  Since  in  practice  it  is 
necessary,  on  account  of  the  varying  thickness  of  different  parts  of  the  body, 
to  vary  also  the  distance  of  the  tube  from  the  plate  between  limits  which 
may  reach  from  twelve  to  twenty-four  inches  or  more,  this  difference  in  time  of 
exposure  becomes  a  very  important  practical  detail.  In  fact,  to  determine  the 
proper  time  of  exposure  for  a  given  case,  in  order  to  produce  a  negative  having 
certain  definite  qualities,  is  the  most  difficult  question  which  the  X-ray  oper- 
ator has  to  answer.  Inasmuch  as  many  of  the  problems  which  are  to  be  solved 
do  not  admit  of  answers  which  can  be  measured  mathematically,  the  elimina- 
tion of  this  single  error  of  the  relation  between  distance  and  time  is  a  matter 
of  a  great  deal  of  consequence.  I  have  prepared  a  table  of  comparative  times 
and  distances,  based  upon  an  exposure  of  ten  seconds  at  a  distance  of  ten  inches, 
and  have  calculated  the  additional  time  necessary  for  all  distances  from  ten 
to  twenty-four  inches.  I  find  this  table  a  useful  aid  for  reference.  In  the 
effort  to  formulate  a  general  rule  for  the  duration  of  exposure  for  the  produc- 
tion of  radiographs,  Donath  ("  Die  Einrichtung  zur  Erzeugung  von  Roentgen- 
Strahlen,"  Berlin,  1899)  has  constructed  a  table  upon  the  following  basis: 
It  is  assumed  that  the  various  parts  of  the  body  possess  a  power  of  absorbing 
X-rays,  which  varies  directly  as  their  density,  and,  if  the  absorbing  power  of 
the  middle  hand  through  the  metacarpal  bones  be  taken  as  the  unit  of  meas- 
urement of  this  quality,  experiment  and  calculation  give  the  following  values 
for  the  absorbing  powers  or  resistance  to  the  passage  of  the  rays  of  the  differ- 
ent parts  of  the  body : 

Resistance 

Hand 1.0 

Forearm 1.4 

Elbow 1.5 

Upper  arm 1.8 

Shoulder-joint 3.0 

Collar-bone 2.7 

Neck 3.0 

Skull 4.5 

Thorax 3-4 

Sternum 3.8 

Foot 1.4 

Knee 2.0 

Leg 1.8 

Thigh 3-5 

Hip-joint -5-6 

Pelvis 8-10 


350  THE   X-EAYS   IN   SURGICAL   DIAGNOSIS 

Donath  has  also  constructed  a  general  formula  for  the  determination  of 
the  proper  time  of  exposure  in  any  required  case.  The  formula  is  based  upon 
the  above  relative  table.      The  terms  are: 

a  =  the  distance  of  the  tube  from  the  plate  in  the  radiograph  of  the  hand. 

b  =  the  distance  of  the  tube  from  the  plate  in  the  picture  which  is  about 
to  be  taken. 

x  =  the  proper  time  of  exposure  sought. 

z  =  the  time  of  exposure  necessary  to  produce  a  radiograph  of  the  hand. 

w  =  the  resistance  of  the  part  of  the  body  which  it  is  proposed  to  take,  com- 
pared with  the  resistance  of  the  hand.  (This  number  is,  of  course,  taken  from 
the  table  of  relative  resistances.) 

The  formula  then  reads : 

x  =  z  X  ^  W. 

(a) 

While  I  have  not  made  practical  use  of  this  formula,  I  fear  that  individual 
variations  in  the  densities  of  the  different  parts  of  the  body  might  sometimes 
render  it  inaccurate.  It  is  necessary,  of  course,  in  every  case  to  establish  the 
unit — i.  e.,  the  time  required  to  take  a  picture  of  the  hand ;  but  a  slender  hand 
is  often  present  in  an  individual  whose  abdomen  is  unusually  thick ;  and  a 
heavily  boned  limb  is  not  infrequently  seen  attached  to  a  comparatively  thin 
trunk.  It  will  be  found  also  that  a  slight  change  in  the  term  W  produces  a 
considerable  change  in  the  term  x. 

In  addition  to  the  variation  in  time  for  distance,  the  much  more  difficult 
problem  remains  to  be  solved  of  estimating  the  various  degrees  of  penetrabil- 
ity for  limbs  of  different  thickness  and  for  individuals  of  different  ages. 
The  tissues  of  children  are  far  less  dense  than  those  of  adults,  and  require  a 
much  shorter  time  even  for  a  given  thickness  of  tissue.  The  tissues  of  women 
are  more  pervious  to  the  rays  than  are  those  of  men,  and  require  a  shorter 
exposure.  To  estimate  the  relative  values  of  these  different  factors  requires 
the  judgment  born  of  experience.  To  lay  down  even  an  approximate  rule 
appears  to  me  quite  unprofitable,  on  account  of  the  extremely  varied  character 
of  the  apparatus  used,  and  the  variations  of  the  same  apparatus  under  differ- 
ent conditions.  With  the  apparatus  which  I  possess,  I  use  chiefly  two  tubes 
for  different  sets  of  cases.  For  all  parts  of  the  body  thinner  than  the  hip-joint 
I  prefer  the  Queen  self-adjusting  tube  with  an  extra  heavy  platinum  anode. 
This  tube  permits  me  to  use  somewhat  less  than  half  the  total  practicable  energy 
of  my  coil.  This  represents  a  heavy  stream  of  sparks,  ten  and  a  half  inches 
long,  measured  on  the  parallel  spark-gap  of  my  coil  and  the  No.  16  platinum 
wire  of  the  Wehnelt  interrupter,  protruded  4  mm.  into  the  acid.  To  obtain  the 
greatest  amount  of  detail  in  my  pictures  of  the  thinner  parts  of  the  body, 
I  use  with  this  tube  a  vacuum  which  corresponds  to  a  resistance  equivalent 
to  from  two  and  a  half  to  three  inches,  measured  on  the  spark-gap  of  the  tube. 
The  current  used  is  the  110  volts  direct  street  current,  and  from  four  to  five 


TECHXIC  351 

amperes.  This  gives  rather  a  black  picture  of  the  hand  in  the  fluoroscope. 
The  bones  appear  very  dark  and  the  soft  parts  somewhat  lighter — but  still  not 
very  light.  The  tube,  in  this  condition,  would  not  be  suitable  for  a  fluoroscopic 
examination  of  the  bones  of  the  leg  nor  even  for  the  elbow-joint  in  the  well- 
developed  male  subject.  When  using  this  tube  for  a  radiograph  picture  of  the 
knee-joint  of  a  well-developed  adult,  I  increase  the  spark-gap  of  the  tube 
to  three  and  a  half  or  four  inches.  This  gives  a  bright,  clear  picture  of  the 
hand  in  the  fluoroscope,  and  in  this  condition  the  tube  would  be  suitable  for  the 
fluoroscopic  examination  of  the  adult  elbow  and  for  a  moderately  well-developed 
leg.  The  necessary  times  of  exposure  to  produce  radiographs  with  this  tube  are 
about  five  times  as  great  as  with  the  cold-water  tubes  of  Dr.  E.  Griinmach, 
about  to  be  described.  This  cold-water  tube  is  intended  to  be  used  on  a  coil 
giving  a  spark  length  of  sixteen  inches.  The  penetrating  and  photographic 
power  of  this  tube  far  exceeds  that  of  any  other  with  which  I  am  acquainted. 
It  can  be  used  with  an  amount  of  energy  equivalent  to  a  very  heavy  stream  of 
sparks  fourteen  inches  in  length  for  from  three  to  four  minutes  continuously, 
without  any  serious  change  of  vacuum.  If  the  current  is  kept  up  for  longer 
than  four  minutes  the  anode  becomes  heated  to  a  dull-red  heat,  and  the  vacuum 
falls  a  little,  but  upon  turning  off  the  current  the  tube  recovers  itself  almost 
completely  in  two  minutes. 

With  this  tube,  using  a  vacuum  representing  a  resistance  equal  to  from 
eight  to  ten  inches  of  spark  length  upon  the  parallel  spark-gap  of  the  coil,  it 
is  possible  to  take  fairly  good  radiographs  of  the  thicker  portions  of  the  extrem- 
ities in  an  astonishingly  short  time.  A  fair  radiograph  of  the  hand  and  fore- 
arm may  be  taken  with  an  exposure  too  short  to  measure — practically  instan- 
taneous. The  knee-joint  may  be  exposed  for  ten  to  fifteen  seconds  with  fair 
result.  I  have  taken  a  very  good  radiograph  of  the  spine,  pelvis,  and  both 
hip-joints  of  a  well-developed  boy,  ten  years  old,  in  thirty  seconds.  The  am- 
perage of  the  current  used  under  these  conditions  was  between  seven  and  eight 
amperes.  Even  shorter  exposures  than  this  are  said  to  be  sufficient.  But  in 
practice  I  find  that  pictures  showing  more  detail  and  slighter  differences  in 
density  can  be  produced  by  a  different  method — i.  e.,  by  reducing  the  resistance 
of  the  tube  and  its  vacuum  to  a  degree  equivalent  to  from  three  to  four  inches 
upon  the  spark-gap  of  the  coil.  When  used  in  this  way,  the  tube  gives  a 
fluoroscopic  picture  of  the  hand  which  is  clear,  but  fairly  dark.  And  yet,  with 
the  tube  in  this  condition,  my  best  radiographs  of  the  spine  and  pelvis  of  adults 
have  been  obtained.  The  exposures  necessary  to  produce  strong  negatives  are 
as  follows : 

Adult  hand  and  wrist,  distance  of  tube  from  plate  13^  inches,  time  ten 
seconds. 

Adult  elbow,  distance  16  inches,  time  thirty  seconds. 

Foot  and  leg,  16  inches,  time  forty-five  seconds. 

Knee-joint,  distance  18  inches  to  2  feet,  time  two  to  two  and  a  half  minutes. 

Shoulder-joint,  21  inches  to  2  feet,  two  and  a  half  minutes. 


352  THE   X-RAYS   IX   SURGICAL  DIAGNOSIS 

Thorax,  distance  2  feet,  three  minutes. 

Adult  hip-joint,  pelvis,  spine,  and  kidney  regions:  females,  four  to  six 
minutes;  males,  six  to  eight  or  even  ten  minutes;  distance,  24  to  26  inches  or 
more. 

I  do  not  find,  however,  that  it  is  possible  with  this  tube  to  get  pictures 
showing  such  slight  differences  of  density  as  with  the  Queen  self-adjusting 
tube,  before  described.  The  farther  away  the  tube  is  placed  from  the  object 
to  be  photographed  the  less  the  distortion  of  the  picture.  In  the  case  of  the 
thinner  parts  of  the  body,  this  distortion  is  only  slight  when  the  tube  is  placed, 
say,  fifteen  or  sixteen  inches  from  the  plate ;  but  when  a  picture  is  taken  of 
the  hip-joints,  including  the  pelvis  of  an  adult,  and  the  tube  is  placed  in  the 
middle  line  of  the  body,  unless  the  distance  of  the  tube  from  the  plate  is  more 
than  two  feet  the  distortion  is  great.  The  practical  lessons  to  be  drawn  are 
that  it  is  advantageous  to  place  the  tube  as  far  away  from  the  body  as  is  con- 
sistent with  a  reasonable  time  of  exposure,  and  in  all  cases  involving  an  ex- 
posure or  exposures  in  the  aggregate  of  five  minutes  or  more  to  lessen  the  risk 
of  dermatitis  by  anointing  the  patient's  skin  abundantly  with  some  greasy 
preparation — lanolin,  for  example — and  by  placing  between  the  tube  and  the 
patient  a  grounded  screen,  consisting  of  thin  cardboard  or  wood  coated  with 
gold  foil,  or  with  a  thin  sheet  of  aluminium.  Whether  these  measures  are  an 
actual  protection  against  burns  or  not,  I  am  unable  to  say,  but  it  is  probable 
that  they  do  serve  to  lessen  the  likelihood  of  a  subsequent  X-ray  burn,  to  some 
degree  at  least.  When  using  powerful  tubes,  with  a  current  of  great  frequency 
of  interruption,  high  intensity,  and  considerable  amperage,  the  possibility  of 
producing  X-ray  burns  when  taking  pictures  involving  several  minutes  of 
exposure  should  never  be  lost  sight  of.     The  danger  is  a  very  real  one. 

If  the  operator  will  keep  an  accurate  record  of  all  the  conditions  under 
which  each  X-ray  picture  has  been  taken,  he  will  gradually  accumulate  a  very 
valuable  series  of  data.  Such  a  record  should  include  the  part  of  the  body, 
the  age  of  the  patient,  the  quality  of  his  tissue — whether  fat  or  lean,  flabby 
or  firm,  whether  large-boned  or  delicately  built — the  distance  of  the  tube  from 
the  plate,  the  particular  tube  used,  the  resistance  of  the  tube  during  the  time 
of  exposure  measured  on  the  spark-gap  of  the  coil,  the  fluoroscopic  picture  of 
the  operator's  hand  during  the  time  when  the  picture  is  taken,  the  position 
of  the  rheostat  lever  or,  better,  the  amperage  of  the  primary  current,  the  kind 
of  plate  used,  the  kind  and  strength  of  the  developer,  and  the  general  char- 
acter of  the  negative. 

Any  examining  table  of  firm  construction  answers  fairly  well  for  taking 
X-ray  pictures.  A  special  table  is,  however,  desirable  for  one  who  wishes  to 
take  up  X-ray  work  seriously ;  there  are  many  such  tables  in  the  market.  A 
table  which  I  had  constructed  answers  the  purpose  well,  and  a  description  of 
it  will  be  found  under  Stereoscopic  Radiography. 

It  is  convenient  to  lead  the  wires  from  the  coil  to  the  tube  over  a  light 
stand  or  framework  of  wood,  which  may  be  elevated  to  a  position  several  feet 


TECHNIC  353 

above  the  patient's  body.  In  this  way  accidental  shocks  arc  prevented,  and 
the  patient  is  less  likely  to  disarrange  the  apparatus  during  clumsy  efforts  to 
get  on  or  off  the  table.  The  operator  is  also  enabled  to  walk  all  around  the 
table  underneath  the  wires,  in  order  to  make  such  adjustments  as  are  necessary. 
The  body  of  the  patient  should  be  placed  upon  the  table  in  such  a  position 
that  the  part  which  it  is  desired  to  show  upon  the  plate  with  the  greatest  clear- 
ness lies  vertically  beneath  the  center  of  the  anticathode.  For  the  determina- 
tion of  this  relation  a  plumb  line  is  useful.  The  patient  must  be  made  com- 
fortable by  means  of  pillows  and  blankets,  so  that  no  part  of  the  body  is  in 
a  condition  of  muscular  tension. 

That  surface  of  the  limb  or  trunk  nearest  to  which  the  lesion  is  supposed 
to  lie  is  placed  next  to  the  plate. 

Some  ingenuity  in  arranging  the  patient  is  required  at  times. 

In  determining  the  question  of  the  distance  of  the  tube  from  the  plate,  it 
is  a  good  rule  to  follow  not  to  put  the  anticathode  nearer  than  twelve  inches 
from  the  skin,  and  for  long  exposures  a  distance  several  inches  greater  should 
be  chosen. 

The  time  of  exposure  for  the  given  case  will  depend,  as  has  already  been 
remarked,  upon  a  number  of  different  factors.  A  high  vacuum  tube  admits 
of  a  short  exposure,  but  the  negative  produced  will  show  but  little  detail.  A 
low  vacuum  tube,  even  with  the  same  current,  will  require  a  longer  time,  but 
will  produce  a  negative  showing  far  more  detail,  and.  will  exhibit  much  slighter 
differences  of  density.  Thus,  if  the  question  to  be  answered  is  merely  what 
is  the  extent  of  deformity  in  a  case  of  fracture,  the  diagnosis  of  fracture  being- 
evident  by  ordinary  means  of  examination,  or  if  it  is  to  be  determined  whether 
or  not  a  metallic  foreign  body  is  present,  a  high  vacuum  tube  with  a  short 
exposure  answers  well.  If,  however,  the  question  relates  to  the  presence  of  a 
calculus,  renal  or  other,  to  disease  of  bone,  or  to  pathological  changes  in  the 
blood-vessels,  or  if,  in  the  case  of  a  tumor,  it  is  supposed  that  the  mass  consists 
partly  of  bone  and  partly  of  softer  structures,  or  in  any  case  in  which  it  is 
desired  to  show  the  greatest  possible  differentiation  of  density,  a  low7  vacuum 
tube  should  be  used  of  just  sufficient  penetration  to  furnish  a  strong  negative 
after  a  reasonably  long  exposure.  I  have  already  given  the  results  of  my  own 
experience,  but  the  reader  will  remember  that  the  time  of  exposure  varies 
much  with  different  forms  of  apparatus. 

And  a  certain  amount  of  experimental  work  is  necessary  to  determine  the 
efficiency  of  any  particular  set  of  apparatus.  The  more  powerful  the  coil 
the  larger  the  energy  of  the  secondary  discharge,  and  the  greater  the  capac- 
ity of  the  tube  to  endure  a  heavy  current  for  a  long  time  the  shorter  the 
exposure. 

The  most  modern  eoils  and  tubes  permit  the  operator  to  use  exposures  quite 
a  little  shorter  than  tliose  I  liave  designated  in  this  chapter;  the  thinner  por- 
tions of  the  body  may  be  taken  with  exposures  almost  instantaneous- — a  second 

or  two  at  most — and  satisfactory  pictures  of  the  hip-joint  and  spine  in  adults 
24 


354  THE   X-KAYS   IN    SUEGICAL  DIAGNOSIS 

of  ordinary  size  may  be  obtained  in  less  than  a  minute.  These  short  exposures 
are  very  desirable;  first,  because  the  danger  of  producing  an  X-ray  burn  is 
reduced  to  a  minimum ;  second,  because  the  patients  are  much  less  likely  to 
move  during  the  exposure,  and  thus  ruin  the  picture;  and  third,  because  the 
patient  is  not  obliged  to  remain  long  in  a  constrained  position. 

Before  turning  on  the  current  the  operator  should  have  informed  himself 
of  a  number  of  details  in  regard  to  his  apparatus.  He  should  know  just  how 
much  energy  the  particular  tube  he  is  using  will  stand,  and  for  how  long; 
and  this  once  determined,  he  should  use  the  same  amount  of  current  and  the 
same  rapidity  of  interruption  with  that  tube  for  every  case  or  his  results  will 
not  be  uniform.  He  should  also  know  by  trial  whether  the  vacuum  of  the 
tube  is  suitable  for  the  case  in  hand.  If  it  is  already  too  low,  the  tube  will 
not  answer  for  that  case ;  if  too  high,  he  must  reduce  it  to  the  proper  point, 
to  be  determined  by  the  parallel  spark-gap  and  the  fluoroscope. 

To  know  what  degree  of  vacuum  in  a  given  tube  is  best  suited  for  a  radio- 
graph of  a  given  case  requires,  above  all  things,  experience.  But  a  general 
idea  may  be  obtained  by  the  appearance  of  the  bones  of  the  hand  in  the  fluoro- 
scope. If  the  shadow  of  the  hand  is  so  dark  that  the  bones  cannot  be  seen 
distinct  from  the  flesh,  the  tube  is  only  suitable  for  the  thinner  parts  of  the 
extremities,  and  for  them  only  in  case  the  tube  in  question  permits  the  use  of 
a  large  amount  of  energy.  The  relation  between  the  penetration,  as  shown  by 
examining  the  bones  of  the  hand,  and  the  power  of  the  tube  to  produce  a  picture 
of  a  part  of  a  given  thickness  is  not  absolute,  but  relative.  For  example,  a 
high  vacuum  tube,  giving  a  good  fluoroscopic  picture  of  the  thorax,  but  which 
permits  the  use  of  a  small  amount  of  energy,  may  entirely  fail  to  produce  a 
satisfactory  picture  of  even  a  part  as  thick  as  the  adult  knee-joint  in  any 
reasonable  time,  whereas,  a  tube  of  very  low  vacuum  indeed,  through  which 
a  heavy  current  may  be  passed  continuously  for  several  minutes,  will  often 
produce  a  good  negative  in  a  much  shorter  time.  A  tube  of  medium  vacuum, 
such  that  the  bones  of  the  hand  when  viewed  through  the  fluoroscope  show 
clear  and  distinct  and  sharply  marked  while  the  flesh  is  much  lighter,  is,  upon 
the  average,  best  for  general  work. 

A  very  high  vacuum  tube  is  of  but  little  use  for  taking  pictures.  The 
operator  will  in  general  be  obliged  to  establish  his  own  standard,  it. being  true 
of  radiography,  as  of  most  other  practical  arts,  that  an  ounce  of  experience  is 
worth  several  pounds  of  precept. 

In  general,  one  is  much  more  likely  to  expose  for  too  short  a  time  rather 
than  for  too  long;  and  whereas  the  negative  produced  by  an  overexposure  is 
still  capable,  with  careful  development,  of  furnishing  a  good  picture,  an  under- 
exposed plate  is  hopeless,  and  no  amount  of  development  will  bring  out  that 
which  is  not  there. 

Distortion. — Owing  to  the  fact  that  the  X-rays  originate  from  a  point  or 
focus  upon  the  surface  of  the  anticathode,  and  proceed  in  straight  lines  in  all 
directions  from  its  surface,  and  since  no  one  has  as  vet  been  able  to  refract  the 


TECHNIC  355 

X-rays  by  means  of  prisms  or  lenses  for  practical  use,  it  admits  of  a  simple 
demonstration  that  the  projections  of  any  two  points  in  the  same  vertical  line 
placed  between  the  surface  of  the  anticathode  and  the  photographic  plate,  but 
removed  from  the  vertical  dropped  from  the  anticathode  on  the  plate,  will  fall 
upon  the  plate  at  two  points  separated  by  a  horizontal  distance  the  extent  of 
which  will  depend  upon  the  distance  of  the  anticathode  from  the  plate,  the 
distance  of  the  two  points  one  from  the  other  vertically,  and  upon  certain  other 
spatial  relations  unnecessary  to  elaborate. 

In  other  words,  a  figure  made  up  of  many  points  situated  at  various  levels 
will  be  projected  upon  the  plate  as  a  distorted  image,  and  apparent  deformities 
will  be  exhibited  in  the  picture  which  do  not  exist.  This  distortion  is  more 
marked  the  nearer  the  tube  is  to  the  plate,  the  thicker  the  object,  and  the 
farther  it  lies  from  the  vertical.  In  the  case  of  the  thinner  parts  of  the  body 
the  distortion  is  slight  at  ordinary  distances,  but  in  radiographs  of  the  hip-joint, 
for  instance,  at  similar  distances  it  becomes  extreme,  and  may  render  the  nega- 
tive quite  worthless  for  diagnostic  purposes.  Distortion  may  be  avoided  by 
placing  the  tube  as  far  away  from  the  plate  as  is  consistent  with  a  reasonable 
time  of  exposure.  To  one  acquainted  with  the  relation  of  the  tube  to  the  plate 
in  any  given  case  and  accustomed  to  inspection  of  X-ray  pictures,  moderate 
degrees  of  distortion  may  be  discounted ;  but,  inasmuch  as  the  medico-legal 
relations  of  radiographs  are  important  in  certain  cases,  it  behooves  us  to  make 
a  careful  adjustment  of  the  tube  and  the  part,  and  to  keep  an  accurate  record 
of  the  data. 

Attempts  on  my  part  to  look  at  distorted  pictures  through  lenses  in  order 
to  correct  the  distortion  have  not  as  yet  met  with  success. 

For  obtaining  good  pictures  not  a  little  depends  upon  the  arrangement  of 
the  part  of  the  body  to  be  photographed  and  upon  absolute  immobility  of  the 
part  during  the  exposure ;  this  latter  may  be  obtained  for  many  parts  of  the 
body  by  means  of  the  straps  attached  to  the  table,  as  described ;  one  or  more 
of  the  straps  may  be  passed  across  the  limb  or  any  other  part,  and  fastened 
quite  tightly. 

The  Compression  Diaphragm. — For  the  purpose  of  keeping  the  patient  quiet, 
of  rendering  the  thickness  of  tissue  to  be  penetrated  as  small  as  possible,  and 
for  the  further  purpose  of  preventing  a  blurred  image  through  the  setting  up 
of  secondary  foci  of  X-rays  in  the  tissues  themselves,  and  bv  the  secondary  rays 
given  off  from  the  general  surface  of  the  tube,  a  special  and  somewhat  com- 
plicated, expensive  and  cumbersome  apparatus  has  been  devised  in  Germany 
by  Dr.  H.  Albers-Schonberg.  The  apparatus  consists  essentially  of  a  cylinder 
of  metal  about  three  inches  in  diameter  and  eight  inches  deep.  This  cylinder 
is  made  to  press  by  the  rim  of  one  of  its  open  ends  firmly  against  the  part  of  the 
body  to  be  pictured,  and  the  X-ray  tube  is  placed  at  the  other  end.  There  are 
further,  diaphragms  with  openings  of  various  sizes  which  may  be  interposed 
between  the  tube  and  the  skin  of  the  patient ;  thus  the  body  is  compressed  by 
the  cylinder,  held  immobile,  and  only  a  limited  area  of  skin  is  exposed  to  the 


356  THE   X-RAYS   IN   SURGICAL   DIAGNOSIS 

rays.  I  am  not  aware  that  the  apparatus  greatly  improves  the  quality  of  the 
pictures  thus  taken,  although  those  who  use  it  believe  that  shorter  exposures 
and  clearer  shadows  are  thus  obtainable — notably  in  pictures  of  the  kidney 
regions  and  lumbar  spine. 

Details  of  Technic. — The  most  important  fact  to  remember  in  taking  a  pic- 
cure  is  that  the  part  you  wish  distinctly  to  show  should  be  as  close  as  possible 
to  the  photographic  plate.  Moreover,  one  should  so  arrange  the  part  that  one 
bone  should  not  overlie  the  image  of  another;  of  course,  this  cannot  always 
be  accomplished,  but  the  effort  in  that  direction  should  be  made.  This  caution 
is  less  important  if  stereoscopic  pictures  are  taken.  If  it  is  believed  that  a 
foreign  body  is  present,  the  part  should  be  placed  so  that  the  portion  of  tissue 
supposed  to  contain  the  foreign  body  is  near  the  plate.  This  is  of  real  im- 
portance in  cases  of  deeply  placed  bullets,  either  in  the  head,  the  trunk,  or  the 
limbs ;  such  a  body  may  sometimes  be  roughly  located  with  the  fluoroscope 
before  the  picture  is  taken. 

Head. — In  taking  pictures  of  the  head  or  face,  the  side  which  it  is  desired 
to  show  distinctly  should  be  firmly  pressed  against  the  photographic  plate,  and 
the  relation  of  the  tube  to  the  skull  and  to  the  plate  should  be  such  as  to  avoid, 
as  far  as  may  be,  the  production  of  a  composite  image  of  the  paired  bones  of 
the  skull  or  face.  This  is  not  always  easy  or  even  possible  to  accomplish,  but 
a  little  practical  experience  is  quite  useful  toward  this  end.  Much  distortion 
of  the  image  will  occur  unless  the  tube  is  placed  from  eighteen  to  twenty-four 
inches  from  the  plate.  Tor  picturing  limited  areas  it  is  often  convenient  to 
use  very  small  plates,  which  may  be  directly  applied,  by  sticking  plaster  or 
other  means,  to  the  skin.  If  the  part  does  not  lend  itself  well  to  the  use  of 
a  plate,  flexible  films  may  be  used  sometimes  with  advantage;  small  pieces  of 
such  films,  done  up  in  black  paper  and  then  in  rubber  tissue,  may  be  used  in 
the  interior  of  the  mouth,  and  thus  excellent  pictures  of  the  teeth  may  be 
obtained. 

The  Shoulder-joint. — One  of  the  most  troublesome  parts  to  take  is  the 
shoulder- joint.  It  is  necessary  that  the  head  of  the  humerus  should  be  firmly 
pressed  against  the  plate.  The  patient  should  lie  upon  his  back  on  the  table, 
the  forearm  of  the  affected  side  should  be  placed  across  the  chest,  with  the 
fingers  upon  the  opposite  clavicle.  It  is  well  to  surround  the  arm  and  the  body 
with  a  few  turns  of  bandage.  The  patient  is  then  rolled  over  toward  the 
affected  side  until  the  shoulder  is  firmly  pressed  against  the  plate ;  the  position 
must  be  maintained  by  firm  cushions  or  sand  bags  placed  under  the  opposite 
shoulder  and  back.  The  pelvis  may  also  be  rotated  in  the  same  direction,  and 
supported  by  a  cushion ;  a  small  cushion  may  be  used  to  support  the  head. 
The  tube  should  be  placed  about  fifteen  inches  above  the  shoulder. 

The  Collar-bone. — The  patient  should  lie  upon  his  face ;  the  arms 
should  be  permitted  to  hang  down  on  either  side  of  the  table.  The  side  of 
the  face  should  rest  upon  the  table ;  no  pillow  should  be  used.  The  plate 
should  be  beneath  the  collar-bone,   and  the  center  of  the  anode  of  the  tube 


TECHNIC  357 

should  be  above  the  middle  of  the  collar-bone  and  distant  eighteen  inches 
or  more. 

The  Cervical  Spine. — The  cervical  spine  may  be  pictured  by  placing  the 
patient  upon  his  side  with  the  plate,  which  will  usually  include  a  portion  of 
the  head,  resting  firmly  against  the  neck  and  the  side  of  the  face.  The  plate 
may  sometimes  be  supported  upon  a  block  of  wood  an  inch  or  more  high. 

The  Thorax. — The  patient  may  lie  either  upon  his  chest  or  upon  his  back, 
according  to  the  anatomical  situation  of  the  lesion  which  it  is  desired  to  show. 
In  order  to  avoid  distortion  the  tube  should  be  placed  as  far  away  as  is  con- 
sistent with  a  fairly  short  exposure.  The  elbow  may  be  most  conveniently 
pictured  by  seating  the  patient  upon  a  low  chair  at  the  side  of  the  table,  and 
arranging  the  limb  upon  the  table  as  may  seem  best  to  suit  the  individual  case. 
The  same  is  true  of  the  forearm  and  hand. 

Spine  and  Kidney  Region. — Pictures  intended  to  show  the  lower  dorsal 
and  lumbar  vertebra?  and  the  pelvis  are  best  taken  with  the  patient  lying  upon 
his  back ;  the  head  should  be  well  raised  from  the  table  with  pillows ;  the  thighs 
should  be  flexed  upon  the  pelvis  and  the  knees  strongly  flexed  upon  the  thighs. 
Only  by  maintaining  such  a  position  as  this  is  it  possible  in  the  average  case 
to  overcome  the  normal  lordosis  of  the  lumbar  spine  and  to  bring  the  back  into 
firm  contact  with  the  plate.  This  position  is  rather  tiresome.  It  may  be 
maintained  without  effort  by  passing  a  long  trunk  strap  across  the  front  of  the 
knees ;  either  end  of  the  strap  is  attached  to  the  table  beyond  the  patient's  head ; 
or  the  strap  may  be  passed  around  the  head  end  of  the  table,  drawn  tight 
across  the  knees,  and  buckled.  The  knees  are  thus  firmly  supported.  The 
abdominal  movements  of  respiration  may  be  controlled  by  a  folded  sheet  drawn 
firmly  across  the  belly.  The  tube  should  be  placed  at  least  a  foot  away  from 
the  surface  of  the  abdomen,  with  the  anode  over  the  middle  line  of  the  body 
and  opposite  to  that  part  which  it  is  desired  to  show  most  clearly  in  the  pic- 
ture. When  seeking  to  detect  stone  in  the  kidney  the  anode  is  placed  over 
the  middle  line  of  the  body,  midway  between  the  umbilicus  and  the  ensiform 
cartilage.  The  surface  of  the  anode  is  directed  toward  the  patient's  head, 
and  at  an  angle  of  from  forty-five  to  sixty  degrees  with  the  horizontal.  The 
use  of  compression  of  the  abdomen  by  a  metal  cylinder  and  a  diaphragm  is 
strongly  recommended  by  many  observers,  the  advantages  being:  (1)  Secondary 
rays  from  the  walls  of  the  tube  and  from  the  tissues  are  avoided ;  (2)  the 
thickness  of  tissue  to  be  penetrated  is  diminished;  (3)  haziness  of  outline 
from  respiratory  movements  is  prevented ;  (4)  the  exposures  may  be  shorter. 
Before  taking  the  picture  the  bowels  and  stomach  should  be  thoroughly  emptied. 

The  Hip-joint. — In  order  to  picture  the  hip-joint  the  patient  should  lie 
flat  upon  his  back,  with  the  thighs  extended.  The  plate  is  placed  beneath  the 
hip  and  the  tube,  with  its  anode  directly  above  the  head  of  the  femur,  at  a 
distance  of  twelve  inches  or  more  from  the  skin.  In  case  it  is  desired  to  show 
both  hip-joints  in  any  patient  larger  than  a  ten-year-old  child,  it  is  better  to 
picture  each  hip-joint  separately,  for  if  the  tube  is  placed  in  the  middle  line 


358  THE   X-KAYS   IN   SUKGICAL  DIAGNOSIS 

of  the  body  with  the  intention  of  showing  both  hips  upon  the  same  plate,  con- 
siderable distortion  will  result  which  might  lead  to  an  error  in  diagnosis  unless 
the  tube  were  placed  so  far  away  as  to  render  an  unduly  long  exposure  neces- 
sary. The  shaft  of  the  femur  may  be  arranged  over  the  plate  in  such  a  position 
as  seems  best  suited  to  the  individual  case. 

.Knee,  Leg,  and  Foot. — The  knee-joint  is  best  pictured  from  the  side,  in 
most  instances ;  the  patient  lies  upon  the  table  upon  his  side,  with  the  limb  to 
be  pictured  next  the  table.  It  is  best  to  strap  the  limb  to  the  table  quite  firmly. 
The  knee  may  be  moderately  flexed  upon  the  thigh.  The  anode  of  the  tube 
should  be  directly  over  the  plane  of  the  articulation.  The  bones  of  the  leg 
may  be  very  well  shown  by  a  side  view  in  either  direction.  The  deformity  of 
Pott's  fracture  is  sometimes  best  shown  by  a  picture  taken  from  before  back- 
ward, with  the  heel  resting  upon  the  plate.  The  ankle-joint  and  the  bones  of 
the  foot  may  be  arranged  in  one  of  a  variety  of  positions  used  to  meet  the 
needs  of  the  particular  case. 

(a)   The  Fluoroscope 

In  surgical  work  the  fluoroscope  furnishes  far  less  valuable  diagnostic  aid 
than  do  radiographs.  In  the  medical  diagnosis  of  the  heart  and  lungs  mere 
broad  differences  in  the  density  of  shadows  are  all  that  is  needed;  in  surgery, 
on  the  other  hand,  details  are  necessary  in  the  picture,  and  these  the  fluoro- 
scope fails  to  reveal.  One  may  entirely  fail  to  recognize  a  fracture"  through 
"the  fluoroscope,  which  shows  with  entire  clearness  in  a  radiograph.  To  recog- 
nize through  the  fluoroscope  the  finer  details  of  bone  structure,  foci  of  disease 
in  bone,  and  the  like,  is  quite  impossible.  Metallic  foreign  bodies  embedded 
in  the  tissues  can  often  be  seen  and  located  with  the  fluoroscope,  but  not  nearly 
so  well  as  by  a  radiograph. 

In  using  the  fluoroscope  the  room  should  be  darkened,  and  the  observer 
should  remain  in  the  darkened  room  for  several  minutes.  Some  form  of 
interrupter  should  be  used  which  gives  a  steady  illumination  of  the  tube, 
the  Wehnelt  interrupter  answers  the  purpose  well.  A  tube  should  be  selected 
such  that  the  rays  are  of  a  proper  penetrating  quality  for  the  part  of  the  body 
to  be  looked  at.  For  the  thinner  parts  of  the  body  a  tube  of  far  less  pene- 
tration is  required  than  if,  for  example,  we  desired  to  examine  the  head  or 
the  adult  hip.  In  order  to  get  the  best  effect  the  fluorescent  screen  should 
be  placed  as  near  the  lesion  which  we  wish  to  see  as*  possible,  and  the  tube 
should  be  as  near  the  interposed  part  of  the  body  as  is  consistent  with  safety 
from  electric  shocks.  The  examination  need  never  last  long  enough  to 
produce  a  burn.  The  part  should  be  examined  from  several  different  direc- 
tions, for  by  this  means  a  fracture  or  foreign  body  may  be  detected  which 
would  otherwise  escape  notice.  My  own  experience  in  the  use  of  the  fluoroscope 
has  been  so  disappointing  and  the  results  so  unreliable  that  I  seldom  use  it 
except  as  a  rough  preliminary  means  of  diagnosis  in  examining  for  fractures 


TECHNIC  359 

or  the  presence  of  foreign  bodies,  or  to  try  to  determine  if  the  efforts  at  reduc- 
tion of  fractures  have  been  successful  after  the  retaining  splints  have  been 
applied. 

(5)   The  Making  of  X-ray  Pictures  and  the  Development   of   the 

Photographic  Plate 

Any  quick  photographic  plate  answers  well  for  taking  X-ray  pictures; 
personally,  I  have  found  that  the  Cramer  X-ray  plates  are  entirely  satisfactory. 
The  plates  should  be  purchased  in  small  numbers,  so  that  they  may  be  fresh, 
and  should  be  put  in  the  containing  envelopes  shortly  before  they  are  to  be 
used.  If  left  for  weeks  in  the  envelopes  a  peculiar  change  occurs  in  the  film, 
causing  a  mottled  and  imperfect  negative.  The  plates  should  be  kept  in  a  room 
as  far  away  from  the  X-ray  machine  as  possible,  or,  if  kept  close  by,  they 
should  be  inclosed  in  a  leaden  box.  Any  of  the  developers  now  popular 
answer  very  well  for  X-ray  pictures,  such  as  pyro,  metol,  hydrochinon,  eichono- 
gen,  rodinal,  glycin,  etc. 

Inasmuch  as  strong  contrasts  are  desirable  in  X-ray  pictures,  what  is  known 
as  a  contrast  developer  is  useful.  I  have  found  that  hydrochinon  gives  good 
results,  the  formula  is  as  follows : 

I.   Hydrochinon    oj  5 

Sodium  sulphite    ovj ; 

Potassium  bromid oss.-oj ; 

Water olxv. 

II.   Sodium  carbonate    §vj ; 

Water   olxv. 

Equal  portions  of  Xo.  I  and  Xo.  II  are  mixed  to  form  the  developer. 

If.  there  is  reason  to  believe  that  a  plate  is  overexposed,  a  diluted  developer 
should  be  used  or  more  bromid-of-potassium  solution  may  be  added.  When 
developing  pictures  of  kidney  stones  or  of  the  hip-joint  and  pelvis,  it  is  well  to 
use  a  weak  developer  on  account  of  the  possible  danger  of  ruining  the  negatives, 
which  cannot  immediately  be  replaced  without  risk  to  the  patient.  To  avoid 
the  danger  of  fogging  an  important  plate  it  is  well  to  carry  on  the  development 
in  absolute  darkness,  only  exposing  the  plate  to  the  red  light  from  time  to  time 
momentarily  in  order  to  judge  howT  the  development  proceeds.  For  the  devel- 
opment of  hip-joint,  spine,  and  pelvis  cases,  from  ten  to  fifteen  minutes  is 
enough ;  for  thinner  parts  of  the  body,  from  six  to  ten  minutes,  according 
to  what  is  desired  to  show.  If  it  is  desired  to  show  with  the  greatest  clearness 
the  structure  of  bone  and  to  blot  out  the  soft  parts  a  form  of  negative  very 
popular  for  purposes  of  exhibition,  lantern  slides,  etc.,  the  development  should 
be  carried  to  a  point  where  the  bones  themselves  appear  distinctly  dark  and  the 
soft  parts  can  scarcely  be  distinguished  from  the  uncovered  portion  of  the  plate. 


360  THE   X-RAYS    IN    SUEGICAL   DIAGNOSIS 

If,  on  the  other  hand,  the  soft  parts  as  well  as  the  bones  are  to  he  pre- 
served on  the  negative,  and  in  all  cases  when  the  radiograph  is  to  he  viewed 
in  the  stereoscope,  a  more  useful  and  interesting  picture  will  he  obtained  by 
stopping  the  development  while  the  soft  parts  are  still  quite  a  little  lighter 
than  their  surroundings  and  the  bones  are  gray  but  perfectly  distinct. 

In  this  description  it  is  assumed  that  the  exposure  has  been  sufficiently  long ; 
otherwise,  no  amount  of  development  will  serve  to  bring  out  detail,  which  is 
simply  not  there. 

A  good  average  negative  will  be  produced  by  carrying  on  the  development 
until  the  plate  becomes  opaque  when  held  up  before  the  source  of  red  light. 

The  use  of  the  so-called  "  acid-hypo  "  bath,  which  hardens  the  gelatin  film 
and  prevents  the  most  annoying  accident,  known  as  "  frilling,"  is  well  worth 
the  additional  trouble  involved  in  its  preparation.  In  summer  it  is  almost 
essential. 

While  those  unaccustomed  to  the  examination  of  X-ray  negatives  sometimes 
find  it  difficult  to  appreciate  what  they  represent,  and  it  is  therefore  necessary 
to  prepare  prints  or  positives,  yet  much  of  the  value  of  the  radiograph  is 
thereby  lost  unless  the  printing  is  in  painstaking  and  skillful  hands.  I  have 
been  unable  to  get  professional  photographers  to  do  this  work  well,  and  there- 
fore do  it  myself  when  I  must,  but  the  surgeon  rarely  has  sufficient  time  to 
devote  to  this,  and  must  put  it  into  the  hands  of  another. 

Satisfactory  prints  of  plates  showing  kidney  and  ureteral  stones  are  espe- 
cially hard  to  make.  The  different  portions  of  the  body  are  inevitably  pene- 
trated to  different  degrees;  and,  in  order  that  every  portion  of  the  plate  should 
be  printed  to  the  proper  density,  it  is  necessary  to  use  screens  of  tissue  paper 
when  printing  by  daylight. 

The  proper  arrangement  of  these  screens  for  a  given  case  must  be  learned 
by  experience. 

(c)    Stereoscopic  Radiography 

The  advantages  of  looking  at  pictures  stereoscopically  are  several.  A  single 
X-ray  plate  shows  the  shadow  of  the  object  pictured  projected  on  one  plane,  and 
thus  the  true  relations  of  points  situated  in  other  places  are  lost.  In  order, 
then,  to  determine  the  position  of  a  foreign  body — a  bullet,  for  example — 
embedded  in  a  limb,  several  methods  are  open  to  us.  We  may  take  two  pic- 
tures through  planes  at  right  angles  to  one  another,  and  by  a  series  of  meas- 
urements from  fixed  points  on  the  surface  of  the  limb  we  may  determine  the 
actual  position  of  the  bullet ;  or  we  may  take  two  pictures  of  the  object  through 
planes  separated  from  one  another  by  angles  less  than  a  right  angle,  and  by 
observing  the  differences  in  size  or  situation,  or  both,  of  the  projected  shadows 
of  the  bullet  on  the  plate,  we  may  by  a  mathematical  calculation,  more  or  less 
simple,  determine  the  position  of  the  bullet  in  the  body. 

The  very  ingenious  localizer  of  Mr.  Mackenzie  Davidson  is  based  upon 
this  principle.     If,  however,  we  take  two  pictures  of  the  bullet  upon  two  sepa- 


TECHNIC  361 

rate  plates  from  two  points  of  view  separated  by  a  distance  equal  to  the  dis- 
tance between  the  visual  axes  of  the  two  eyes,  the  points  of  view  being  in  a 
plane  parallel  with  the  surface  upon  which  the  shadows  are  projected — i.  e., 
the  plane  of  the  photographic  plate — the  distance  being  in  this  case  about  two 
inches  and  a  half,  and  then  view  the  two  radiographs  in  a  stereoscope,  the 
two  images  will  combine  to  form  a  single  picture,  and  the  image  of  the  bullet 
will  be  seen  in  its  relations  to  the  bones,  the  'surrounding  soft  parts,  and  the 
skin  with  sufficient  clearness  to  cut  down  upon  it  without  further  calculation 
other  than  such  as  may  be  furnished  by  our  anatomical  knowledge.  This 
quality  of  stereoscopic  radiographs  which  permits  us  to  see  structures  at  dif- 
ferent depths  in  perspective  is  of  great  value,  also,  in  the  diagnosis  of  the 
deformities  following  fractures  and  dislocations,  and  in  the  recognition  of 
the  gross  pathological  changes  taking  place  in  diseases  and  tumors  of  bones. 

Whoever  has  attempted  to  recognize  the  exact  amount  and  character  of 
the  displacement  in  a  recent  case  of  fracture  from  a  single  X-ray  picture,  or 
even  from  two  pictures  taken  from  different  points  of  view  and  looked  at 
separately,  must  frequently  have  suffered  vexatious  disappointment. 

On  the  other  hand,  stereoscopic  pictures  of  fractures  show  the  relative 
positions  of  the  displaced  fragments  in  a  very  satisfactory  manner.  The  exact 
relations  of  the  bones  of  a  dislocated  joint  are  seen  with  great  clearness.  The 
limits,  and  often  the  character,  of  tumors  growing  from  or  attached  to  the 
bones  may  usually  be  clearly  appreciated.  The  situation  of  sequestra  and  of 
tubercular  foci  in  bone  can  sometimes  be  seen  in  a  satisfactory  way. 

Apparatus  for  Taking  Stereoscopic  Pictures. — In  order  to  take  stereoscopic 
X-ray  pictures  certain  mechanical  aids  are  necessary. 

First,  a  device  which  permits  the  X-ray  tube  to  be  moved  a  measured  dis- 
tance in  a  horizontal  or  vertical  plane,  so  that  the  two  pictures  may  be  taken 
from  separate  points  of  view  in  the  same  plane,  distant  from  one  another  two 
inches  and  a  half,  equivalent  nearly  to  the  distance  between  the  pupils  of  the 
two  eyes.  In  other  words,  the  principle  is  the  same  as  is  used  in  taking  ordi- 
nary stereoscopic  photographs  by  means  of  lenses.  By  this  means,  as  in  ordi- 
nary binocular  vision,  we  get  the  impression  of  depth  or  perspective  when 
viewing  a  solid  object  having  points  in  more  than  one  plane.  As  applied  to 
radiography,  we  use,  of  course,  no  lens;  but,  after  having  taken  one  picture, 
we  displace  the  tube  two  inches  and  a  half,  the  movement  being  made  parallel 
to  the  surface  of  the  photographic  plate,  and  make  a  second  exposure.  The 
second  device  is  used  to  enable  us,  after  taking  one  picture,  to  remove  the 
exposed  plate  and  to  substitute  for  it  another,  which  shall  occupy  exactly  the 
same  position  as  the  first  did,  and  that  without  disturbing  the  object  to  be  pic- 
tured. For  holding  the  X-ray  tube  above  the  body  of  the  patient  and  permit- 
ting the  movement  of  the  tube  through  a  measured  distance,  I  find  the  fol- 
lowing apparatus  convenient : 

A  heavy  cylindrical  bar  of  hard  wood,  two  inches  in  diameter,  is  fixed  ver- 
tically to  one  side  of  the  table.     This  bar  may  be  moved  vertically  a  measured 


362  THE    X-KAYS    IN    SUKG1CAL   DIAGNOSIS 

distance,  or  horizontally  from  one  end  of  the  table  to  the  other,  and  may, 
moreover,  be  rotated  on  a  vertical  axis  and  fixed  in  any  desired  position  by 
means  of  a  friction  clamp  fastened  to  a  traveling  block,  which  slides  in  hori- 
zontal grooves  along  the  side  of  the  table.  Two  other  sliding  blocks,  one  on 
either  side,  serve  as  guides  to  any  predetermined  position  of  the  first.  From  the 
upper  end  of  this  vertical  arm  there  extends  a  horizontal  arm  of  wood  long 
enough  to  permit  the  X-ray  tube  to  be  suspended  from  it  by  means  of  a  heavy 
wooden  clamp  over  any  point  across  the  width  of  the  table.  This  horizontal 
arm  is  scaled  in  inches,  so  that  the  clamp  which  carries  the  tube  can  be  moved 
along  it  a  measured  distance.  The  clamp,  also  of  wood,  hangs  vertically 
downward  from  the  horizontal  arm,  and  at  its  lower  end  bears  a  pair  of  grooved 
jaws  padded  with  rubber,  so  placed  that  when  the  horizontal  arm  is  at  right 
angles  with  the  long  axis  of  the  table  the  X-ray  tube  is  very  firmly  held  with 
the  plane  of  the  anticathode  at  an  angle  of  forty-five  degrees  with  the  surface 
of  the  table,  and  with  the  long  axis  of  the  tube  parallel  with  the  long  axis  of 
the  table.  The  construction  of  this  gallows  frame,  as  it  may  be  called,  is  of 
hard  wood,  and  very  heavy  for  the  sake  of  rigidity.  Metal  should  be  avoided 
as  far  as  possible  in  its  construction.  The  vertical  arm  is  so  graduated  in 
inches  that  the  observer  may  read  at  a  glance  the  distance  from  the  center  of 
the  anticathode  of  the  table  to  the  photographic  plate  beneath  it  on  the  table 
(see  Fig.  130).  The  rotation  of  the  whole  gallows  frame  upon  a  vertical 
axis  is  very  convenient.  By  means  of  this  device  the  tube  may  be  accurately 
adjusted  over  any  desired  point  of  the  table.  The  horizontal  arm  may  then 
be  rotated  to  a  position  which  permits  the  patient  to  get  upon  the  table  with- 
out risk  of  injuring  the  apparatus.  After  the  arrangement  of  the  patient  upon 
the  table,  the  gallows  may  be  rotated  to  its  former  position  and  the  exposure 
made. 

The  second  device  necessary  permits  the  removal  of  the  photographic  plate 
from  beneath  the  patient  and  the  substitution  of  a  second  photographic  plate 
without  moving  the  patient.  For  those  who  desire  seriously  to  interest  them- 
selves in  practical  radiography,  the  possession  of  a  special  table  adds  greatly 
to  the  convenience  of  the  operator.  I  have  found  a  table  constructed  upon 
the  following  plan  convenient:  The  table  is  made  of  hard  wood,  built  heavily 
for  the  sake  of  stability.  It  is  6  feet  long,  19^  inches  wide,  and  34^  inches  high, 
and  is  supported  upon  eight  strong  wooden  legs.  The  upper  surface  of  the 
table  contains  three  rectangular  openings,  one  in  the  center  of  the  table  and  one 
at  either  end.  These  openings  are  I7f  inches  long  and  14f  inches  wide.  This 
corresponds  to  the  size  of  fourteen  by  seventeen  X-ray  plates  in  their  envel- 
opes. Over  the  entire  top  of  the  table  is  stretched  a  sheet  of  pegamoid 
with  a  canvas  backing,  held  under  tension  by  a  row  of  brass-headed  tacks  around 
the  edge  of  each  opening,  and  further  by  a  half-round  molding  nailed  to  the 
edge  of  the  table.  The  solid  portions  of  the  upper  surface  of  the  table  are 
padded  with  a  sheet  of  felt,  slightly  thicker  than  an  X-ray  plate  included  in 
its  envelopes. 


TECHNIC  363 

Beneath  the  table,  and  corresponding  accurately  in  size  and  situation  to  the 
openings  above  described,  are  three  wooden  plate  carriers,  which  slide  verti- 
cally up  and  down  in  suitable  guides  (see  Fig.  130).  Each  carrier  is  raised 
and  lowered  by  means  of  strong  wooden  supports  beneath  the  table  arranged  in 
the  form  of  a  toggle-joint.  When  the  elbow  of  the  joint  is  straightened,  the 
plate  carriers  are  raised  and  pressed  firmly  upward  against  the  pegamoid  cov- 
ering of  the  table.  When  bent,  the  plate  carriers  descend  and  permit  the  intro- 
duction or  removal  of  the  photographic  plates.  A  suitable  space  is  provided  for 
this  purpose  at  one  side  of  the  table. 

The  position  of  the  plates  upon  the  carriers  is  accurately  fixed  by  means 
of  wooden  kits  of  different  sizes.  The  lower  limbs  of  the  toggle-joints  are 
pivoted  beneath  the  table  upon  a  heavy  iron  bar,  which  extends  the  whole  length 
of  the  table.  The  weight  of  the  patient's  body  overlying  the  carriers  is  thus 
firmly  supported.  Upon  the  pegamoid  surface  of  the  table  the  position  of  the 
several  sizes  of  plates  is  clearly  marked  by  shallow  grooves  in  the  cloth  cor- 
responding to  the  situation  of  the  plates  beneath.  The  part  to  be  pictured 
may  thus  be  arranged  upon  the  surface  of  the  table  with  reference  to  the  under- 
lying plate.  Along  either  border  of  the  table,  and  below  the  level  of  its  upper 
surface,  three  pairs  of  metal  knobs  or  buttons  are  fastened  opposite  to  each 
opening.  To  these  buttons  thin  leather  straps  are  affixed  at  pleasure.  They 
may  be  buckled  across  the  part  to  be  pictured,  thus  securing  complete  immobil- 
ity during  the  exposure. 

For  those  who  do  not  possess  a  special  table  the  following  device  is  inex- 
pensive and  fairly  satisfactory.  Upon  a  framework  of  planking,  two  feet  long 
and  as  wide  as  the  table  which  is  to  be  used  for  taking  radiographs,  are  nailed 
two  little  cleats  or  strips  of  wood,  a  quarter  of  an  inch  high,  running  crosswise 
from  one  side  of  the  planking  to  the  other,  separated  by  a  distance  a  little 
greater  than  the  width  of  the  envelope  which  inclosed  that  size  of  photographic 
plate  which  is  to  be  used.  Across  the  top,  from  one  strip  of  wood  to  the  other, 
is  tacked  a  sheet  of  stiff  fiber  paper,  as  it  is  called.  A  shallow  wooden  drawer 
or  plate  carrier  is  made  of  such  a  size  and  depth  that  it  slides  easily  in  and 
out  between  the  strips  of  wood  and  beneath  the  fiber  cover. 

Methods  of  Taking  Stereoscopic  Pictures. — The  part  to  be  radiographed  is 
placed  upon  the  fiber  covering;  the  plate  in  its  envelope  is  then  put  into  the 
wooden  drawer,  which  can  be  easily  inserted  beneath  the  fiber  cover.  A  pic- 
ture having  been  taken,  the  drawer  is  pulled  out,  the  plate  removed,  a  new  plate 
inserted  beneath  the  part  to  be  pictured,  and  a  second  picture  taken.  It  is 
sometimes  necessary,  and  usually  wise,  to  hold  the  part  to  be  pictured  abso- 
lutely quiet  by  strips  of  adhesive  plaster  stuck  to  the  skin  of  the  patient  and 
to  the  table. 

If  the  tube  has  been  moved  horizontally  two  inches  and  half  after  taking 
the  first  picture,  the  two  negatives,  when  developed,  constitute  stereoscopic  pic- 
tures, and  may  be  at  once  viewed  in  the  reflecting  stereoscope. 

Another  method  of  taking  stereoscopic  pictures  is  to  have  a  plate  holder 


364  THE   X-EAYS   IN   SURGICAL   DIAGNOSIS 

so  constructed  that  one  half  the  contained  photographic  plate  is  shielded  from 
the  action  of  the  rays  by  a  heavy  sheet  of  metal.  After  exposing  one  half  the 
plate,  that  half  is  shielded  by  the  metal  screen  and  the  other  half  is  brought 
beneath  the  patient. 

The  tube  is  moved  a  suitable  distance,  and  a  second  exposure  is  made. 
The  two  pictures  thus  lie  side  by  side  upon  the  same  plate,  and  may  be  copied  in 
a  reduced  size,  and  viewed  as  positives  on  glass  or  paper  in  a  refracting  stereo- 
scope. 

Apparatus  for  Viewing  Stereoscopic  Kadiographs. — For  viewing  stereoscopic 
radiographs  two  forms  of  apparatus  may  be  used:  First,  the  Wheatstone  Re- 
flecting Stereoscope,  which  permits  us  to  examine  X-ray  negatives  of  any  size 
immediately  after  they  have  been  developed.  Manifestly,  a  great  saving  of 
time,  for  it  is  possible  to  examine  the  plates  in  a  stereoscope  within  an  hour 
of  the  time  they  have  been  taken,  or  the  negatives  may  be  reduced  in  size  to 
three  and  a  quarter  by  four  inches,  mounted  side  by  side,  viewed  as  positives 
on  glass  or  on  paper  in  the  refracting  stereoscope  in  common  use. 

The  principle  of  the  Wheatsone  Reflecting  Stereoscope  is  as  follows:  Two 
rectangular  plane  mirrors  are  fixed  upon  a  suitable  wooden  frame,  so  that  two 
of  their  edges  being  in  contact,  their  surfaces  stand  at  an  angle  of  ninety 
degrees  to  one  another. 

If,  now,  an  observer  places  his  eyes  on  either  side  of  the  apex  of  the  angle 
made  by  the  mirrors,  and  if  stereoscopic  pictures  of  any  object  be  placed  one 
opposite  each  mirror,  the  surface  of  the  picture  making  an  angle  of  forty-five 
degrees  with  the  planes  of  the  mirrors,  the  observer  will  see  the  reflected  image 
of  the  right-hand  picture  with  his  right  eye  and  the  image  of  the  left-hand  pic- 
ture with  his  left  eye.  And  if  the  adjustments  are  suitable,  the  brain  will 
combine  the  two  images  into  a  single  image,  which  will  appear  in  relief.  This 
principle  may  be  utilized  for  viewing  radiographs  in  two  ways.  Prints  may 
be  made  from  stereoscopic  X-ray  negatives  and  placed  one  upon  either  side 
of  the  mirrors.  The  advantage  of  this  method  is  that  a  very  simple  form  of 
apparatus  answers  perfectly.  Two  pieces  of  plane  glass  mirror  stuck  together 
along  one  straight  edge  and  placed  upon  a  table  at  right  angles  to  one  another, 
with  the  apex  of  the  angle  directed  toward  the  observer's  eyes,  answers  as  well 
as  anything. 

The  photographic  prints  are  placed  one  on  either  side,  supported  by  a 
grooved  block  of  wood.     Daylight  furnishes  a  satisfactory  illumination. 

The  disadvantages  are,  the  time  and  trouble  necessary  for  the  preparation 
of  the  prints,  the  inability  to  view  the  pictures  for  at  least  forty-eight  hours 
after  they  have  been  taken,  and  the  loss  of  detail  which  occurs  when  printing 
on  paper  from  X-ray  negatives,  unless  unusual  care  and  skill  are  used  in  the 
process. 

Second,  the  original  X-ray  negatives  may  be  viewed  by  transmitted  light 
in  the  Wheatstone  Reflecting  Stereoscope.  The  advantages  of  this  method 
are  that  the  stereoscopic  effect  is  appreciated  in  a  very  satisfactory  manner; 


TECHXTC  365 

that  none  of  the  details  are  lost;  that  the  plates  may  lie  viewed  in  the  stereo- 
scope immediately  after  development,  within  one  hour  after  the  time  the  pic- 
tures are  taken,  a  practical  advantage  of  great  consequence  in  cases  of  recent 
fractures  and  dislocations.  And  in  cases  where  foreign  hodies  are  to  be  detected 
and  located,  the  time  and  trouble  of  preparing  the  prints  are  saved.  The  dis- 
advantages are  that  a  somewhat  more  expensive  and  complicated  apparatus  is 
necessary  to  produce  satisfactory  results.  The  plates  must  be  illuminated  by 
a  source  of  artificial  light  placed  on  either  side  of  the  plane  mirrors.  The 
light  must  be  diffused ;  hence,  it  is  necessary  to  interpose  in  front  of  each  light 
a  screen  of  ground  glass  or  opal  glass.  In  front  of  the  screen  on  either  side 
are  placed  the  X-ray  negatives.  The  center  of  each  negative  should  be  nearly 
opposite  the  apex  of  the  angle  made  by  the  mirrors. 

This  apparatus  may  be  constructed  in  a  simple  form  at  a  cost  of  less  than  five 
dollars.  The  mirrors,  six  inches  square  or  thereabouts,  may  be  set  in  grooves 
on  a  block  of  wood ;  other  grooved  blocks  of  wood  may  be  placed  on  either  side 
to  hold  the  plates  and  the  pieces  of  ground  glass.  Two  electric-light  bulbs  or  two 
oil  lamps,  one  on  either  side,  serve  as  a  source  of  light.  Any  ordinary  desk 
or  table  furnishes  a  level  base  for  the  entire  apparatus.  The  smallest  prac- 
tical experience  only  is  necessary  to  arrive  at  a  knowledge  of  the  best  relative 
positions  of  the  several  portions  of  the  stereoscope.  In  order  to  obtain  the 
very  best  effects,  a  somewhat  costly  and  elaborate  mechanism  is  desirable. 
With  the  apparatus  already  described,  the  diffused  light  of  the  room,  together 
with  reflections  and  shadows  of  one  sort  or  another,  serve  to  obscure  to  some 
degree  the  finer  shades  of  different  density  in  the  X-ray  negatives ;  and  since 
the  proper  interpretation  of  these  slight  differences  is  often  of  great  consequence 
in  the  diagnosis,  any  device  which  serves  to  preserve  these  qualities  of  the 
negatives  as  perceived  by  the  eye  is  a  distinct  advantage. 

I  have  found  that  inclosing  the  whole  apparatus  in  a  nearly  light-tight  box 
serves  this  purpose  well.  A  small  square  aperture  is  left  in  front  of  the  box 
opposite  the  apex  of  the  angle  made  by  the  mirrors  through  which  the  observer 
looks.  The  Folmer  and  Schwing  Manufacturing  Company,  of  Xew  York,  have 
made  for  me  a  stereoscope  of  this  kind.     Its  construction  is  as  follows : 

A  heavy  framework  of  wood,  five  feet  in  length  and  one  foot  wide,  serves 
as  a  base  for  the  apparatus.  The  framework  bears  upon  its  surface  polished 
wooden  tracks,  upon  which  rest  wooden  blocks  bearing  tracks  at  right  angles 
to  those  beneath.  The  several  parts  of  the  apparatus  bear  upon  these  tracks, 
thus  permitting  motions  in  two  directions — namely,  along  the  length  of  the 
plank  and  at  right  angles  thereto.  The  mirrors  in  the  center  and  the  plate 
holders  upon  either  side  are  inclosed  in  a  light-tight  box  of  wood  and  leather. 

An  orifice  four  inches  and  a  half  square  is  left  in  front  of  the  box  opposite 
the  apex  of  the  angle  made  by  the  mirrors.  The  plate  holders  permit  the  use 
of  plates  measuring  eleven  by  fourteen  inches  and  eight  by  ten  inches.  In 
addition  to  the  horizontal  movements,  the  plate  holders  may  be  moved  vertically 
up  and  down  by  means  of  a  rack  and  pinion.     These  movements  of  the  plate 


366  THE   X-EAYS   IN   SURGICAL   DIAGNOSIS 

holders  in  three  planes  permit  any  desirable  adjustment  to  be  made.  The 
interior  of  this  central  portion  of  the  apparatus  is  painted  a  dead  black.  Upon 
either  side  opposite  to  the  plate  holders  is  a  sheet-iron  box  lined  with  opal 
glass,  and  containing  twelve  sixteen-candle  power  electric-light  bulbs.  These 
may  be  illuminated  in  groups  of  six.  The  sides  of  the  boxes  toward  the  plate 
holders  contain  a  groove  for  the  reception  of  a  sheet  of  opal  glass,  ground  glass, 
or  colored  glass ;  or,  by  a  combination,  the  light  may  be  passed  through  col- 
ored glass  and  ground  or  opal  glass  at  will.  When  using  the  apparatus,  the 
negatives  are  placed  in  the  frames,  the  lights  are  turned  on,  and  the  observer 
places  his  eyes  in  front  of  the  window  in  the  center  of  the  mirror  box.  The 
images  are  then  seen  in  the  two  mirrors  with  the  right  and  left  eyes  respectively. 
By  moving  the  mirrors  a  little  away  from  or  toward  the  eyes,  the  two  images 
unite  and  form  a  single  stereoscopic  picture,  the  stereoscopic  effects  produced 
with  this  apparatus  leaving  nothing  to  be  desired. 

Another  method  of  viewing  stereoscopic  X-ray  pictures  is  to  photograph 
the  two  negatives  in  a  reducing  camera.  The  pictures  should  be  reduced  to 
lantern-slide  size — viz.,  three  inches  and  a  quarter  by  four  inches — thus  two 
positives  on  glass  are  produced.  These  are  then  mounted  side  by  side  on  a 
plain  glass  backing,  and  are  viewed  most  conveniently  in  a  refracting  stereo- 
scope inclosed  in  a  bellows.  In  order  to  produce  the  best  effects,  a  piece  of 
ground  glass  should  be  inserted  between  the  pictures  and  the  source  of  light. 

The  Folmer  and  Schwing  Manufacturing  Company  have  made  for  me  a 
refracting  stereoscope  which  answers  the  requirements  exceedingly  well. 

Method  of  Producing-  X-ray  Pictures. — "For  the  production  of  X-ray  pictures 
to  be  viewed  in  the  refracting  stereoscope,  the  methods  used  for  the  making  of 
lantern  slides  answer  well.  Slow  plates  should  be  used,  three  inches  and  a 
quarter  by  four  inches  in  size,  and  to  get  the  greatest  amount  of  detail,  a  small 
diaphragm  and  a  long  exposure,  about  one  hour  for  ordinarily  dense  nega- 
tives, with  skylight  reflected  from  a  mirror  on  a  cloudy  day  and  passed 
through  a  sheet  of  ground  glass.  A  developer  giving  great  contrast  and  slow 
development,  hydrochinon  and  bromid,  for  example,  is  desirable.  Direct  light 
from  the  sky  is  best ;  it  may  be  obtained  in  the  city  by  the  use  of  a  large  mirror 
set  outside  the  window  at  an  angle  of  forty-five  degrees  with  the  vertical,  the 
sky  light  being  thus  reflected  into  the  room.  In  order  that  the  two  pictures 
may  combine  in  the  stereoscope,  they  must  occupy  the  same  relative  position 
on  the  two  plates.  In  order  to  accomplish  this  I  have  found  the  following 
procedure  useful :  After  the  image  of  the  large  plate  is  accurately  focused  on  the 
ground-glass  screen,  best  by  first  focusing  on  some  printed  matter  or  the  like, 
and  then  substituting  for  it  the  X-ray  negative,  measurements  in  two  direc- 
tions at  right  angles  one  to  the  other  are  taken  from  some  bony  point  and  line 
of  the  reduced  image  to  the  edges  of  the  ground-glass  screen.  These  measure- 
ments are  noted,  and  the  image  of  the  second  negative  is  made  to  conform  pre- 
cisely to  them.  The  two  pictures,  when  mounted,  will  be  found  in  the  correct 
position.     These  reduced  stereoscopic  positives  on  glass  are  very  satisfactory, 


THE   DIAGNOSTIC    VALUE    OF   THE   X-EAYS  367 

and  appeal  strongly  to  those  who  are  unaccustomed  to  examine  and  interpret 
X-ray  negatives. 

There  is  usually  one  relative  position  in  which  stereoscopic  pictures  show 
to  the  best  advantage.  They  are,  so  to  speak,  rights  and  lefts.  If  the  picture 
taken  when  the  tube  was  farthest  to  the  right  is  viewed  with  the  right  eye,  and 
the  other  with  the  left  eye,  the  stereoscopic  image  will  appear  with  the  dorsal 
or  ventral  surface  of  the  limb  toward  the  observer,  according  as  the  dorsal  or 
ventral  surface  was  next  the  photographic  plate.  If  the  position  of  the  pictures 
is  reversed,  the  limb  will  appear  as  though  looked  at  from  the  opposite  surface, 
and  usually  one  of  these  arrangements  is  optically  more  satisfactory  than  the 
other.  The  apparent  point  of  view  may  also  be  changed  by  turning  the  sepa- 
rate pictures  to  face  the  other  way  without  changing  their  relative  positions ; 
but  once  mounted  together  side  by  side  in  permanent  relation,  no  amount  of 
turning  will  change  the  apparent  point  of  view ;  so  that  if  it  is  desired  to  view 
the  pictures  from  both  directions,  they  must  either  be  kept  separate  or  else  two 
pairs  must  be  mounted  in  different  relative  positions. 

In  taking  X-ray  pictures  for  stereoscopic  effects,  it  is  desirable  that  distor- 
tion of  the  image  should  be  avoided  as  far  as  may  be.  A  distance  of  from  twenty- 
six  to  twenty-eight  inches  from  antieathode  to  photographic  plate  is  sufficient 
to  prevent  undue  distortion,  unless  both  hip- joints  of  an  adult  are  taken  on 
one  plate,  in  which  case  it  is  better  to  remove  the  tube  sill  farther  away.  To 
formulate  any  rule  for  determining  the  proper  time  of  exposure  in  a  given  case 
is  very  difficult.  The  operator  must  know  what  his  apparatus  is  capable  of 
doing,  and  experience  is  the  only  guide.  The  tendency  is  to  underexpose  rather 
than  the  contrary. 

III.    THE   DIAGNOSTIC   VALUE   OF  THE  X-RAYS  IN  INJURIES  AND 

DISEASES 

(a)  Fractures,  Dislocations,  and  Deformities  of  Bone 

The  X-ray  Diagnosis  of  Fractures. — The  diagnostic  value  of  the  X-rays  in 
fractures  can  hardly  be  overestimated.  With  perfect  technic  and  suitable  ap- 
paratus it  is  scarcely  possible  for  a  fracture  of  any  of  the  bones  of  the  extrem- 
ities or  of  the  shoulder  girdle  to  escape  detection.  Fractures  of  the  skull  and 
of  the  bones  of  the  face  are  less  easily  detected  by  this  means.  Fractures  of 
the  neck  of  the  femur  can  be  detected  in  nearly  all  cases.  Fractures  of  the 
pelvis  may  or  may  not  be  detected,  according  to  their  situation,  and  fractures 
of  the  cervical  spine  are  usually  detected  with  ease.  Fractures  of  the  remain- 
der of  the  spine  can  be  detected  under  favorable  conditions.  Fractures  of  the 
ribs  can  usually  be  detected  without  much  difficulty. 

Certain  Limitations. — The  limitations  of  the  X-ray  in  detecting  fractures 
depend  upon  the  impossibility  of  bringing  certain  bones  or  parts  of  bones  in 
close  proximity  to  the  photographic  plate.     The  shadows  of  such  parts  as  the 


368  THE    X-EAYS    IN    SITKGICAL   DIAGNOSIS 

bones  of  the  extremities,  except  the  upper  portion  of  the  femnr,  may  be  made 
so  clear  and  distinct  that  no  fracture  can  exist  and  fail  to  show  in  the  negative. 
Fractures  with  much  displacement  or  comminution  will,  of  course,  show  even 
in  a  very  inferior  negative ;  but  incomplete  fractures,  impacted  fractures,  and 
fractures  with  little  or  no  displacement,  or — assuming  that  a  single  picture  only 
has  been  taken — fractures  in  which  the  displacement  is  in  only  one  plane,  and 
that  in  the  plane  of  the  rays  as  they  fall  upon  the  plate,  may  fail  to  show 
unless  the  picture  be  very  good  indeed,  or  unless  stereoscopic  negatives  are 
made  and  viewed  in  a  stereoscope.  In  any  pair  of  negatives,  if  the  details  of 
the  cancellous  bone  structure  at  the  suspected  point  of  fracture  can  be  clearly 
made  out  and  no  fracture  can  be  seen  in  the  stereoscope,  there  is  no  fracture 
present.  It  is  in  doubtful  cases  that  stereoscopic  negatives  furnish  the  most 
valuable  evidence. 

The  difficulty  of  detecting  fractures  with  displacement  in  only  one  plane 
can  of  course  be  overcome  by  taking  two  pictures  in  planes  at  right  angles  one 
to  the  other.  This  measure  does  not  always  overcome  the  difficulty  in  im- 
pacted fractures  or  in  incomplete  fractures,  and  in  these  cases  stereoscopic 
radiographs  furnish,  in  many  instances,  the  only  reliable,  and  sometimes  the 
indispensable,  data  for  a  correct  diagnosis. 

With  pictures  taken  and  viewed  singly,  unless  the  rays  fall  in  such  a 
manner  as  to  show  some  displacement  or  some  actual  space  between  the  frag- 
ments of  bone  the  fracture  may  entirely  escape  detection;  that  is  to  say,  to 
make  the  matter  more  clear  by  an  example,  let  us  assume  that  a  patient  has  a 
transverse  fracture  of  the  lower  end  of  the  radius  with  only  a  little  dorsal 
displacement,  and  that  a  picture  is  taken  in  the  ordinary  way  by  placing  the 
hand  and  forearm,  palm  downward,  upon  the  photographic  plate.  If  the 
anode  of  the  tube  is  placed  directly  above  the  point  of  fracture,  the  break  in 
the  bone  may  or  may  not  show  upon  the  negative ;  if  the  anode  of  the  tube  is 
placed  a  few  inches  above  or  below  the  vertical  dropped  through  the  point  of 
fracture,  the  point  of  view  becomes  an  oblique  one;  the  outlines  of  the  bone 
structure  will  overlie  one  another  in  such  a  manner  that  the  fracture  will 
probably  escape  observation  in  the  negative.  If  stereoscopic  pictures  of  the 
same  fracture  are  taken,  from  no  matter  what  position  of  the  anode  of  the 
tube,  the  fracture  and  the  displacement  will  stand  out  as  'plainly  in  the  stereo- 
scopic image  as  though  one  viewed  the  bared  bone  with  the  naked  eye.  When, 
however,  we  attempt  to  produce  radiographs  of  such  a  quality  in  pictures  of 
the  adult  hip-joint,  we  often  fail  to  obtain  the  minute  details  of  bone  structure 
necessary  for  a  diagnosis  in  cases  where  there  is  little  or  no  displacement,  or 
where  the  fracture  is  impacted  without  much  change  in  the  normal  outline  of 
the  bone.  Under  favorable  conditions  we  may  succeed  in  producing  a  good 
enough  negative  for  our  purposes,  but  if  the  individual  is  large  and  stout,  the 
difficulties  are  at  times  very  great.  This  is  notably  true  of  stout  women  the 
thickness  of  whose  buttocks  raises  the  skeleton  some  distance  from  the  under- 
lying table. 


THE   DIAGNOSTIC    VALUE    OF   THE   X-EAYS  369 

The  general  statement  may  then  be  made  that,  whenever  the  details  of  bone 
structure  can  be  shown,  the  detection  of  fractures,  wherever  situated,  admits 
of  almost  absolute  accuracy.  When  a  picture  of  this  quality  is  for  any  reason 
not  obtained,  a  fracture  may  still  exist  and  not  be  evident  in  an  X-ray  picture. 

Separation  of  the  epiphyses,  when  these  are  still  united  by  a  layer  of  car- 
tilage to  the  shafts  of  the  long  bones,  can  be  detected  whenever  the  separation 
is  attended  by  displacement,  otherwise  not,  since  cartilage  casts  a  very  faint 
shadow,  indeed  so  faint  that  the  detection  of  loose  portions  of  cartilage  not 
containing  deposits  of  earthy  salts  is  quite  impossible. 

One  of  the  results  of  the  very  general  use  of  the  X-rays  in  the  diagnosis 
of  fractures  has  been  to  demonstrate  the  fact  that  a  perfect  functional  result 
is  compatible  with  a  good  deal  of  displacement  of  the  bony  fragments ;  and, 
further,  that  the  best  efforts  of  skillful  surgeons  sometimes  fail  to  reduce  the 
displacements  of  simple  fractures.  This  is  so  far  true  that  it  is  sometimes 
unwise  to  permit  patients  to  see  the  radiographs  of  their  healed  fractures  lest, 
although  the  function  of  the  limb  may  be  in  every  way  good,  dissatisfaction 
may  result  when  the  patient  realizes  that  the  fragments  of  the  bone  are  not 
in  their  true  anatomical  relations.  Many  suits  for  damages  have  been  brought 
on  these  grounds  alone. 

The  X-ray  Diagnosis  of  Dislocations. — While  the  recognition  of  dislocations 
is  generally  quite  easy  by  the  ordinary  methods  of  examination,  it  sometimes 
happens  that  in  the  particular  case  a  doubt  may  exist  as  to  the  character  of 
the  dislocation,  or  as  to  whether  a  fracture  coexists  or  not.  In  these  cases 
X-ray  pictures,  and  especially  stereoscopic  X-ray  pictures,  afford  valuable  aid. 
It  is  clear  from  what  has  already  been  stated  that  in  dislocations  the  true 
relations  of  the  displaced  bones  must  be  perfectly  evident  when  viewed  stereo- 
scopically,  and,  indeed,  experience  shows  that  this  is  the  case;  the  bones  stand 
out  in  their  true  relations,  and  the  diagnosis  of  the  displacement  can  be  made 
at  a  glance.  In  order  to  make  the  correct  diagnosis  of  dislocations  uncom- 
plicated by  fractures  it  is  not  necessary  to  obtain  a  picture  showing  bone 
structure.  Very  thin  negatives,  indeed,  suffice;  and,  oddly  enough,  two  nega- 
tives, neither  one  of  which  is  good  enough  to  base  any  conclusion  upon  at 
all,  will,  when  united  as  a  stereoscopic  image,  afford  a  surprising  amount  of 
information. 

The  X-ray  Diagnosis  of  Deformities  of  Bone. — It  goes  without  saying  that 
gross  deformities  of  bone,  arising  from  ancient  injury  or  from  disease,  can  be 
very  clearly  shown  in  X-ray  pictures ;  this  is  also  true  of  congenital  deformities 
— club-foot,  for  example.  In  cases  where  the  relations  between  the  smaller 
bones  are  disturbed,  or  where  one  or  more  bones  remain  undeveloped,  or  where 
supernumerary  bones  exist,  or  where  one  or  more  bones  are  wanting — stereo- 
scopic pictures  of  such  deformities  give  a  far  better  idea  of  the  relations  of  the 
parts  than  even  dissected  specimens,  because  the  bones  are  seen  as  they  exist 
in  life  while  acted  upon  by  the  muscles  and  held  in  position  by  the  ligaments. 

In  cases  of  imperfect  or  arrested  development  of  the  skeleton    quite  unsus- 
25 


370  THE   X-KAYS   IN   SUEGICAL  DIAGNOSIS 

pected  degrees  of  difference  between  the  size,  shape,  and  position  of  the  bones 
of  the  two  sides  of  the  body  may  be  revealed  by  the  X-rays. 

(b)   X-kay  Diagnosis  of  Diseases  of  Bone 

The  various  diseases  of  bone  involving  changes  in  the  bone  structure,  such 
as  rarefying  osteitis,  osteosclerosis,  caries,  necrosis,  the  productive  inflamma- 
tions of  bone  (syphilitic  or  other),  tumors  of  bone  (whether  productive  or 
destructive),  loss  of  substance  in  bone,  may  in  the  more  accessible  parts  of 
the  body  be  shown,  and  even  diagnosticated  with  considerable  accuracy,  by 
means  of  the  X-rays. 

In  rarefying  osteitis  the  shadow  cast  by  the  bone  is  not  only  less  dense, 
but  the  increased  size  of  the  spaces  in  the  cancellous  tissue  is  easily  recognized. 
The  increased  density  and  thickness  of  the  cortical  layer,  the  diminished  size 
or  absence  of  a  medullary  cavity  in  bones  the  seat  of  osteosclerosis,  are  often 
easily  recognized  in  a  good  radiograph.  Tuberculous  cavities  in  the  bones  of 
children  and  tuberculous  sequestra  can  often  be  seen  with  exquisite  clearness 
in  good  pictures,  and  the  diagnosis  of  these  bony  lesions  is  sometimes  to  be 
made  with  perfect  accuracy,  even  without  the  confirmatory  evidences  to  be  seen 
and  felt  in  the  soft  parts  surrounding  a  joint.  The  detection  of  cavities  or  of 
tuberculous  sequestra  in  the  articular  extremities  of  the  long  bones  is  sometimes 
possible  before  the  invasion  of  the  surrounding  soft  parts  or  of  the  joint 
structures  has  occurred- — i.  e.,  at  a  most  favorable  time  for  operative  removal. 

In  syphilitic  and  other  productive  inflammations  of  bone  the  character  and 
extent  of  the  lesion  can  often  be  shown  clearly.  The  character  of  tumors  of 
bone,  whether  composed  of  dense  or  porous  bony  tissue,  and  the  size,  position, 
and  structure  of  the  attachment  of  the  tumor  to  the  healthy  bone,  can  be  readily 
made  out  in  most  instances.  In  the  destructive  tumors  of  bone  the  thickness 
and  character  of  the  bony  layer  surrounding  the  tumor,  the  amount  of  destruc- 
tion of  bone  tissue,  and  even  the  limits  of  the  infiltration  of  the  bone  with 
tumor  tissue,  can  in  the  majority  of  instances  be  appreciated  quite  well.  I  was 
able  in  one  case  to  demonstrate  fairly  well  the  presence  of  an  osteosarcoma 
growing  from  the  anterior  surface  of  the  sacrum. 

(c)  The  Detection  and  Location  of  Foreign  Bodies  by  Means  of  the 

X-kays 

Metallic  bodies,  pieces  of  glass,  and  any  mineral  substance,  whether  in 
the  form  of  a  solid  mass  or  a  powder,  may  be  detected  when  embedded  in  the 
tissues  in  most  instances  with  ease.  The  exact  location,  however,  of  such  a 
foreign  body  is  a  different  matter.  There  are  certain  facts  to  be  borne  in  mind : 
the  nearer  the  foreign  body  is  to  the  plate,  the  more  sharp  will  be  its  shadow 
and  the  nearer  will  the  shadow  be  to  the  actual  size  of  the  body;  the  farther 
away  from  the  plate  the  more  the  shadow  will  be  distorted  and  increased  in 


THE   DIAGNOSTIC    VALUE    OF   THE   X-EAYS  371 

size,  so  that  if  a  body  of  known  character  and  size  appears  sharp  and  clear  in 
the  negative,  it  cannot  be  far  from  the  skin  surface  which  lies  next  the  plate. 
The  simplest  way  to  locate  a  foreign  body  such  as  a  needle  or  a  bullet  is  to 
take  stereoscopic  pictures  of  the  part  containing  the  body.  By  this  means 
the  body  may  be  located  in  many  instances  with  sufficient  accuracy  to  permit 
the  surgeon  to  cut  down  upon  it  readily  enough.  The  depth  of  the  body 
from  the  surface  and  its  relation  to  the  bones  can  be  clearly  appreciated  in 
the  stereoscopic  image.  Another  method  is  to  take  two  pictures  in  planes  at 
right  angles  one  to  the  other.  By  measurements  taken  from  bony  points  to 
the  position  of  the  shadows  of  the  foreign  body,  and  by  measurements  from 
the  shadow  of  the  surface  of  the  limb,  the  position  of  the  body  may  be 
determined. 

The  Mackenzie  Davidson  Localizing  Apparatus. — Various  ingenious  methods 
and  forms  of  apparatus  have  been  devised  for  locating  foreign  bodies  accurately. 
Among  the  best  of  these  is  the  localizing  apparatus  of  Mackenzie  Davidson. 
The  principle  of  this  apparatus  is  as  follows:  The  part  containing  the  foreign 
body  is  placed  upon  the  photographic  plate,  a  picture  is  then  taken,  the  tube 
is  then  moved  a  known  distance  horizontally  and  a  second  picture  is  taken 
without  moving  the  part  pictured  upon  the  plate.  Two  shadows  of  the  foreign 
body  are  thus  cast  upon  the  same  plate  separated  by  a  distance  which  depends 
upon  the  distance  of  the  tube  from  the  plate,  the  distance  the  tube  has  been 
moved  horizontally,  and  the  distance  of  the  foreign  body  itself  from  the  plate, 
or,  in  other  words,  the  depth  at  which  it  lies  buried  in  the  tissues.  Mr.  Mac- 
kenzie Davidson  fastens  threads  to  a  horizontal  bar  separated  from  the  negative 
below  by  a  distance  equal  to  the  distance  of  the  anode  of  the  tube  from  the 
plate  at  the  time  the  exposures  were  made;  the  threads  are  then  brought  in 
contact  with  some  particular  point  of  the  shadow  of  the  foreign  body  upon 
the  negative  placed  below.  The  second  thread  is  placed  upon  the  corresponding 
point  of  the  other  shadow  of  the  foreign  body.  The  point  of  intersection  of 
these  threads  indicates  the  position  of  the  foreign  body  with  reference  to  the 
photographic  plate  when  the  exposures  were  made.  A  full  description  of  the 
apparatus  will  be  found  in  "  The  Roentgen  Rays  in  Medical  Work,"  David 
Walsh,  M.D.,  Edin.,  2d  edition,  1899,  William  Wood  &  Co.,  p.  93  et  seq.  By 
means  of  this  apparatus  foreign  bodies  may  be  located  with  absolute  accuracy. 
For  many  purposes  so  accurate  a  localization  is  unnecessary. 

Dr.  Sweet's  Localizer. — Dr.  Sweet  has  devised  a  localizer  for  the  purpose 
of  detecting  and  locating  foreign  bodies  in  the  eye.  It  may  be  used  for  locating 
foreign  bodies  in  the  brain.  I  quote  Dr.  Sweet's  description  of  the  apparatus, 
together  with  the  method  of  its  use  {Trans,  of  the  Amer.  Surg.  Assn.,  vol.  xxi, 
1903,  p.  479  et  seq.)  : 

The  methods  employed  in  locating  foreign  bodies  by  the  Roentgen  rays  are  all 
based  upon  the  triangulation  of  the  planes  of  shadow  of  the  body,  with  the  X-ray 
tube  in  two  different  positions.     Measurements  of  the  distance  of  the  crossing  of 


372  THE   X-EAYS   IN    SURGICAL  DIAGNOSIS 

these  planes  from  one  or  more  points  marked  upon  the  skin  give  the  exact  situation 
of  the  foreign  substance. 

Accuracy  of  localization  depends  upon  a  knowledge  of  the  position  of  the  tube 
at  the  two  exposures,  its  distance  from  the  photographic  plate,  and  upon  the  proper 
marking  of  one  or  more  spots  upon  the  skin  by  opaque  substances  that  will  cast 
shadows  upon  the  plate.  A  special  form  of  apparatus  achieves  these  results  in  the 
most  satisfactory  manner: 

The  apparatus  for  locating  foreign  bodies  is  similar  in  principle  to  that  em- 
ployed so  successfully  during  the  past  few  years  in  determining  the  situation  of 
pieces  of  metal  in  the  eyeball.  I  have  recently  designed  a  new  form  of  localizer, 
which  is  shown  in  the  accompanying  illustrations.  It  consists  of  a  firm  base,  the 
top  of  which  is  covered  with  sheepskin,  and  is  crossed  by  two  steel  wires  at  right 
angles  to  each  other.  A  sliding  drawer  on  one  side  permits  the  changing  of  the 
photographic  plate  without  disturbing  the  position  of  the  patient.  A  hollow 
upright  bar  attached  to  one  side  of  the  base  supports  three  movable  rods.  One  rod 
has  its  extremity  pointed,  over  which  slips  an  indicating  ball.  The  other  rods  are 
employed  to  indicate  the  situation  of  the  tube  at  the  two  exposures.  The  center 
of  the  indicating  ball  is  directly  above  the  crossing  of  the  two  wires  on  the  base, 
and  its  height  is  shown  by  a  scale  upon  the  upright  bar. 

The  head  or  other  portion  of  the  body  containing  the  foreign  substance  to  be 
located  rests  upon  the  top  of  the  base  portion,  the  cross  wires,  previously  inked, 
leaving  a  mark  upon  the  skin.  The  indicating  rod  is  lowered  until  the  ball  rests 
upon  the  skin,  and  this  spot  is  also  indicated  with  ink.  The  distance  of  the  ball 
above  the  cross  wires  is  read  from  the  graduated  scale. 

The  X-ray  tube  is  placed  from  eighteen  to  twenty  inches  above  the  plate,  and 
the  distance  of  the  anode  of  the  tube  carefully  measured.  One  exposure  is  then 
made  with  the  tube  directly  above  or  to  one  side  of  the  indicating  ball,  and  a  second 
plate  made  with  the  tube  from  three  to  four  inches  from  the  first  position. 

After  development  the  plates  show  the  shadows  cast  by  the  cross  wires,  the  indi- 
cating ball,  and  the  foreign  body.  The  distance  of  the  foreign  substance  from  the 
marks  upon  the  skin  of  the  patient  may  be  determined  by  plotting  upon  a  flat 
surface  the  position  of  the  tube,  indicating  ball,  and  the  cross  wires  at  the  two 
exposures,  and  finding  the  crossing  of  the  planes  of  x  shadow  of  the  foreign  body. 
This  method  is  the  one  employed  in  eye  work,  and  is  equally  accurate  in  dealing 
with  other  portions  of  the  body,  although  somewhat  more  complicated.  For  this 
reason  I  have  employed  threads  to  indicate  the  crossing  of  the  planes  of  shadow 
in  the  new  localizing  apparatus — a  method  which  has  been  developed  by  Mackenzie 
Davidson,  of  London. 

The  method  of  employing  the  indicating  apparatus  is  as  follows :  A  tracing  of 
the  two  negatives  is  made  upon  a  transparent  sheet  of  celluloid,  with  the  point  of 
crossing  of  the  wires  corresponding.  This  celluloid  sheet  is  placed  upon  the  top 
of  the  base  of  the  apparatus  with  the  tracing  of  the  shadow  of  the  cross  wires 
directly  above  the  point  of  crossing  of  the  wires.  The  indicating  rod  is  moved  to 
the  height  it  occupied  at  the  time  the  exposures  were  made.  A  thread  is  now 
passed  from  the  spot  on  the  celluloid  representing  the  shadow  of  the  indicating 
ball  at  one  exposure,  touches  the  point  of  the  indicating  rod  representing  the  center 
of  the  ball,  and  is  continued  the  exact  distance  that  the  tube  was  away  from  the 
plate  when  the  radiograph  was  made.    A  second  thread  passes  in  the  same  manner 


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374  THE   X-EAYS   IX    SURGICAL  DIAGNOSIS 

from  the  shadow  of  the  indicating  ball  at  the  second  exposure.  The  threads  are 
kept  taut  by  lead  weights  in  the  hollow  upright  tube.  These  two  threads  accu- 
ratehy  indicate  the  lines  of  shadow  of  the  indicating  ball  at  the  two  exposures,  and 
also  the  position  of  the  tube.  If  the  ends  of  the  threads  resting  upon  the  shadows 
of  the  indicating  ball  are  now  moved  to  the  spots  on  the  transparent  celluloid  rep- 
resenting the  shadows  made  by  the  bullet,  their  crossing  will  show  its  position  in 
the  tissues  in  relation  to  the  indicating  ball  and  cross  wires.  The  distance  of  this 
point  of  crossing  from  the  indicating  ball  gives  the  location  of  the  body  in  the 
tissues  as  measured  from  the  spot  on  the  skin  at  which  the  ball  rested  when  the 
two  plates  were  made.  The  situation  of  the  bullet  may  also  be  measured  from  the 
cross  wires.  The  depth  of  the  body  will  determine  which  of  the  two  points  is  to  be 
chosen  in  plotting  the  position  of  the  body  for  operation.  The  location  of  each 
fragment  of  the  bullet  is  similarly  determined. 

The  apparatus  was  made  for  me  by  Queen  &  Co.,  of  Philadelphia. 

(d)  The  Recognition  of  Tumors  and  Diseases  of  the  Soft  Parts  by 

Means  of  the  X-rays 

Large  aneurisms,  cysts,  enlarged  kidneys,  and  abscesses  may  often  be  demon- 
strated clearly  by  means  of  an  X-ray  picture.  It  is  necessary  to  use  a  tube  of 
rather  low  resistance  in  order  to  show  slight  differences  in  the  density  of  the 
structures  penetrated.  It  sometimes  happens  that  the  course  of  a  suppurating 
tract  in  the  tissues  is  difficult  to  follow  by  ordinary  means.  If  such  a  tract  can 
be  injected  with  an  emulsion  of  bismuth,  it  can  often  be  shown  in  its  entirety 
by  means  of  a  radiograph  whether  it  be  situated  in  the  soft  parts  or  in  bone. 
The  boundary  of  a  dilated  stomach  can  be  quite  clearly  shown  by  the  admin- 
istration of  a  considerable  quantity  of  bismuth  emulsion  by  the  mouth.  A 
more  general  application  of  this  method  will  readily  occur  to  surgeons  in  suit- 
able cases.  The  size  of  solid  and  cystic  tumors  of  the  abdomen  can  often  be 
determined  by  means  of  an  X-ray  picture. 

(e)  The  Detection  of  Pathological  Concretions — Stone  in  the  Kidney, 

Ureter,  Urinary  Bladder,  and  Biliary  Calculi 

While  it  cannot  be  said  that  the  X-rays  are  an  infallible  means  of  detecting 
the  presence  or  absence  of  calculi  in  the  kidney,  in  the  ureter,  and  in  the 
urinary  bladder,  still  the  accumulated  experience  of  many  observers  leads  to 
the  conclusion  that  the  X-rays  furnish  a  certain  means  of  diagnosis,  positive  and 
negative,  in  a  large  proportion  of  cases.  The  limitations  of  the  X-rays  in  this 
field  are  due  partly  to  the  character  of  the  stones  themselves,  partly  to  imperfec- 
tions, hitherto  unavoidable,  in  the  apparatus  employed,  partly  to  errors  of  teeh- 
nic,  including  the  faulty  use  of  the  X-rays,  the  imperfections  in  photographic 
plates,  and  errors  in  the  interpretation  of  the  developed  photographic  negative. 

Chemical  Composition  of  Kidney  Stones. — We  may  first  consider  the  diffi- 
culties due  to  the  chemical  constitution  of  the  stones  which  we  wish  to  detect. 


THE    DIAGNOSTIC    VALUE    OF    THE    X-RAYS 


375 


Chemical  examination  of  any  large  number  of  kidney,  ureter,  and  bladder 
stones  shows  that  they  consist  mainly  of  three  sets  of  ingredients,  namely, 
oxalate  of  lime,  uric  acid,  and  the  phosphates  of  the  alkaline  earths.  In  addi- 
tion to  these  common  ingredients  we  find,  rarely,  stones  composed  of  cystin  of 
sulphur  and  of  indican;  these  last  are,  however,  so  rarely  present  that  for 
practical  purposes  they  may  be  excluded.  The  stones  originating  in  the  pelvis 
of  the  kidney — unless  the  kidney  is  already  the  seat  of  inflammatory  disease 


Fig.  133. — Author's  X-ray  Table  for  taking  Stereoscopic  Radiographs.  In  the  position 
shown  in  the  illustration  the  three  drawers  for  the  reception  of  photographic  plates  are  shown 
open  as  at  B.  Upon  the  table  are  standing  two  kits  for  holding  photographic  plates  of  8  X  10  and 
11  X  14  inches;  when  no  kit  is  used  the  drawer  admits  a  plate  of  14  X17  inches  (D).  At  C  is  shown 
the  toggle-joint  by  which  the  photographic  plates  are  pressed  firmly  upward  against  the  pegamoid 
covering  of  the  table  and  by  means  of  which,  after  an  exposure  has  been  made,  the  photographic 
plate  can  be  moved  and  replaced  by  another  without  in  any  wise  disturbing  the  position  of  the 
patient.  At  A  is  shown  the  vertical  wooden  pillar,  together  with  its  horizontal  arm,  both  grad- 
uated in  inches  for  holding  the  X-ray  tube.  At  E  is  shown  the  wooden  clamp  which  grasps  the 
tube.  By  means  of  this  arrangement  it  is  possible  to  place  the  tube  readily  a  measured  distance 
above  the  photographic  plate,  or  to  move  the  tube  horizontally,  for  the  purpose  of  taking  stereo- 
scopic pictures.  The  table  was  made  for  me  by  the  Folmer  &  Schwing  Manufacturing  Company, 
of  New  York.     In  use  it  has  been  found  very  satisfactory. 

causing  its  own  symptoms  of  a  character  sufficiently  marked  to  overshadow 
the  symptoms  produced,  by  the  stone  itself — consist  of  oxalate  of  lime,  uric 
acid,  or  both.  We  further  find  that  stones  consisting  chiefly  of  uric  acid 
contain  a  fairly  large  proportion  of  oxalate  of  lime,  and  that  pure  oxalate 
stones  without  any  uric  acid  are  of  comparatively  rare  occurrence. 

I  collected  a  considerable  number  of  stones  from  various  sources  supposed 
to  contain  uric  acid  and  nothing  else ;  they  were  subjected  to  chemical  exam- 
ination, and  it  was  found  that  although  a  very  few  consisted  of  uric  acid  alone, 


376  THE   X-EAYS    IN    SUKGICAL   DIAGNOSIS 

nearly  all  contained  ten  per  cent  or  more  of  oxalate  of  lime.  A  series  of 
experiments  were  then  conducted  by  placing  stones  of  various  sizes  and  of  vari- 
ous and  known  composition  upon  photographic  plates  along  with  portions  of 
human  ribs,  a  finger,  biliary  calculi  and  stones  inclosed  in  masses  of  muscular 
tissue  and  in  recently  extirpated  human  kidneys;  these  plates  were  then  ex- 
posed to  X-rays  emanating  from  tubes  of  various  penetrating  qualities,  for 
different  times  and  with  different  quantities  of  electrical  energy.  The  results 
of  these  experiments  were  to  show  that  oxalate  of  lime  stones  cast  very  dense 
shadows ;  the  same  was  true,  to  a  somewhat  less  degree,  of  phosphatic  stones. 
It  was  further  found  that  in  the  case  of  uric-acid  stones,  containing  even  ten 
per  cent  of  oxalate  of  lime,  the  shadows  were  still  quite  dense.  Pure  uric-acid 
stones,  on  the  other  hand,  appeared  to  be  very  permeable  to  the  X-rays ;  the 
shadows  cast  by  them  were  faint  and  were  readily  blotted  out;  the  same  was 
true,  and  to  nearly  a  like  degree,  of  biliary  calculi. 

Conditions  Necessary  for  Success  and  Limitations  of  the  MetJiod. — In  order 
to  detect  successfully  a  stone  in  the  pelvis  of  the  kidney  it  is  necessary  to 
produce  a  negative  which  shall  show  distinctly  the  additional  density  of  the 
stone  as  compared  with  the  shadow  cast  by  a  very  thick  portion  of  the  human 
body ;  and,  as  a  matter  of  practical  experience,  it  is  found  that  oxalate-of-lime 
stones,  phosphatic  stones,  and  uric-acid  stones,  containing  some  proportion  of 
oxalate,  can,  whether  in  the  ureter  or  kidney,  under  ordinary  conditions  be 
detected  with  a  fair  degree  of  certainty,  even  though  they  are  of  small  size; 
biliary  calculi  and  uric-acid  stones,  on  the  other  hand,  cannot. 

In  a  man  weighing  one  hundred  and  seventy-five  pounds  I  was  able,  on 
three  successive  occasions,  to  detect  an  oxalate  stone,  weighing  one  grain,  in 
the  ureter.  The  stone  was  passed  per  urethram  soon  after  the  last  picture  was 
taken.  The  progress  of  the  stone  down  the  ureter  was  clearly  shown  in  the 
successive  pictures.  In  a  rather  slender  girl  of  sixteen  a  stone  weighing  one 
half  grain  in  the  renal  pelvis  was  clearly  shown  upon  the  plate.  The  stone 
was  removed,  with  another  larger  stone,  by  operation,  and  was  found  to  consist 
of  equal  parts  of  uric  acid  and  oxalate  of  lime. 

When  the  individual  is  large  and  stout  and  has  a  thick  abdomen,  the  diffi- 
culties are  enormously  increased :  longer  exposures  are  needed  to  penetrate  the 
body,  the  stone  itself  is  much  further  removed  from  the  photographic  plate,  and 
there  are  apt  to  occur  vague  and  ill-defined  shadows,  rendering  a  correct  inter- 
pretation of  the  plate  impossible.  It  is  true  that  improved  apparatus  has 
rendered  the  number  of  failures  smaller,  but  many  still  occur.  It  is  found 
that  in  these  cases  the  best  results  are  obtained  by  forcing  the  largest  possible 
amount  of  current  through  the  tube  for  a  short  time  rather  than  by  using  less 
current  and  a  longer  exposure.  In  this  way,  with  the  best  obtainable  tubes 
and  a  coil  giving  a  very  heavy  discharge,  pictures  of  kidney  stones  may  be 
taken  in  a  minute  or  less.  At  the  end  of  this  time  the  vacuum  of  the  tube 
usually  breaks  down  aud  ceases  to  furnish  rays  of  sufficient  penetrative  power. 

In  certain  instances  errors  in  the  development  of  the  plate  may  destroy 


THE   DIAGNOSTIC    VALUE   OE    THE    X-KAYS  377 

its  value.  If  the  plate  has  been  sufficiently  exposed  and  is  developed  too  far 
the  shadow  of  the  stone  may  be  blotted  out.  The  best  pictures  are  usually 
obtained  with  tubes  of  not  too  great  a  penetrative  power,  furnishing  rays  that 
show  the  greatest  possible  amount  of  gradation  in  the  shadows  of  the  tissues. 
A  tube  which  gives  a  fluoroscope  picture  of  the  hand  so  bright  that  the  bones 
are  nearly  blotted  out  is  not  as  suitable,  according  to  my  experience,  for  show- 
ing the  slighter  differences  of  density  as  is  a  tube  of  lower  vacuum.  The 
experience  of  some  observers  seems  to  differ  from  mine  upon  this  point,  and 
I  should  not  wish  to  make  my  assertion  too  positive.  The  quality  of  an  X-ray 
picture  necessary  to  enable  one  to  exclude  the  presence  of  stones  in  the  kidney 
or  ureter  should  be  such  that  the  transverse  processes  of  the  lumbar  vertebra?, 
the  last  two  ribs,  the  borders  of  the  psoas  muscles  on  either  side  of  the  verte- 
bra', show  sharply  and  plainly.  The  shadow  of  the  stone  itself  will,  if  in  the 
pelvis  of  the  kidney,  be  found  a  little  below  the  last  rib  and  about  two  and 
one  half  inches  from  the  spinal  column.  If  the  stone  is  large,  a  very  distinct 
shadow  will  be  cast,  so  that  sometimes  the  weight  of  the  stone  may  be  guessed 
at  within  a  few  grains. 

In  poorer  negatives  the  shadow  may  be  very  faint,  and  special  methods 
of  illumination  are  necessary  in  order  properly  to  interpret  the  plate.  For 
the  study  of  such  negatives,  and  as  a  convenient  method  of  examining  any 
X-ray  picture,  a  cubical  metal  box  is  used  the  top  of  which  is  composed  of 
opal  glass ;  in  the  box  are  several  electric-light  bulbs ;  an  X-ray  negative  is 
laid  upon  the  opal  glass  and  the  interior  of  the  box  illuminated  ;  in  this  way 
the  lights  and  shadows  of  the  plate  can  be  studied  to  the  best  advantage.  In 
case  a  shadow  is  found  suggesting  the  presence  of  a  stone,  a  second  picture 
should  be  taken  to  confirm  the  diagnosis,  for  the  reason  that  imperfections  in 
the  film  or  in  the  impregnation  with  the  silver  salt  may  give  rise  to  shadows 
closely  resembling  those  made  by  stones,  and  further  similar  shadows  are  some- 
times cast  by  hardened  masses  of  intestinal  contents  (these  may  be  avoided  by 
having  the  bowel  thoroughly  emptied  before  the  picture  was  taken).  Should 
the  second  picture,  taken  after  an  interval  of  several  days,  show  a  shadow 
identical  in  size  and  position  with  the  first,  the  diagnosis  of  stone  is  reason- 
ably sure. 

If  no  shadow  is  seen  resembling  a  stone,  what  is  the  value  of  the  negative 
diagnosis?  If  the  quality  of  the  picture  is  excellent  and  the  individual  is 
not  notably  stout,  the  presence  of  an  oxalate  or  phosphate  concretion  may  be 
excluded  with  reasonable  certainty.  In  those  cases,  however,  in  which  the 
pelvis  of  the  kidney  contains  minute  phosphatic  concretions  arranged  irregu- 
larly in  amorphous  masses,  no  definite  shadow  may  be  produced.  If  the  stone 
consisted  of  pure  uric  acid  it  would  probably,  in  my  experience,  fail  to  cast 
a  definite  shadow ;  certain  skillful  observers  have,  however,  succeeded  in  identi- 
fying pure  uric-acid  stones. 

Stone  in  the  Ureter. — The  lower  one  third  of  the  ureter  is  the  portion  in 
which  stones  ordinarily  become  impacted.     They  are  commonly  found  in  the 


378  THE   X-RAYS    IN    SURGICAL   DIAGNOSIS 

negative  below  the  lower  border  of  the  ischium,  and  rather  near  the  outer  bor- 
der of  the  sacrum.  For  detecting  stones  in  the  lower  portion  of  the  ureter  it  is 
best  to  place  the  anode  of  the  tube  over  the  umbilicus,  or  even  a  little  lower 
down.  A  frequent  source  of  error  is  the  appearance  upon  the  plate  of  sharply 
marked,  rounded  shadows,  varying  in  size  from  that  of  a  JSTo.  5  shot  to  that 
of  a  dried  pea;  these  shadows  are,  however,  placed  usually  farther  away  from 
the  middle  line  than  the  course  of  the  ureter;  they  often  appear  near  to  and 
upon  a  level  with  the  spine  of  the  ischium,  sometimes  lower  down,  and  in  one 
instance  they  appeared  to  lie  in  the  region  of  the  prostate  gland.  The  nature 
of  these  shadows  has  not,  as  far  as  I  am  aware,  been  determined;  they  may 
represent  concretion  in  the  veins  or  in  the  ligaments ;  they  occur  in  both  men 
and  women;  I  have  not  observed  them  until  the  fourth  decade  of  life.  In 
my  own  experience,  stones  in  the  ureter  are  easier  to  detect  than  in  the  kidney. 

Stone  in  the  Urinary  Bladder. — Stone  in  the  urinary  bladder  may  be  discov- 
ered so  readily  by  other  means  that  it  is  rarely  necessary  to  resort  to  the  X-rays 
for  a  diagnosis.  X-ray  pictures  of  bladder  stones  are,  in  my  experience,  uni- 
formly successful.  The  tube  may  be  placed  in  the  same  position  as  is  used 
for  the  detection  of  stone  in  the  ureter. 

Experience  in  Detection  of  Renal  and  Ureteral  Calculi. — My  personal  experi- 
ence in  detecting  renal  and  ureteral  calculi  is  embodied  in  the  following  extract 
from  a  paper  I  wrote  on  this  topic  several  years  ago : 

My  own  experience  is  limited  to  about  125  cases  examined.  I  have  not 
succeeded  in  detecting  a  pure  uric-acid  calculus.  Among  the  earlier  cases 
examined  was  one  in  which,  owing  to  want  of  experience,  a  shadow  upon  the 
plate  was  believed  to  be  a  stone,  but  was  found  to  be  due  to  a  defect  in  the 
gelatin.  The  patient  was  operated  on  and  no  stone  was  found.  In  thirty  cases 
a  positive  diagnosis  was  made  by  means  of  one  or  more  skiagraphs,  and  the 
presence  of  stone  was  confirmed  by  the  operation. 

Of  the  stones  discovered,  in  twenty-six  cases  the  stone  or  stones  were  in 
the  pelvis  of  the  kidney  or  extreme  upper  end  of  the  ureter.  In  four  cases  the 
stones  were  in  the  pelvic  portion  of  the  ureter. 

One  stone  of  oxalate  of  lime  weighing  less  than  a  grain  and  a  half  was 
found  on  three  different  occasions  in  the  ureter,  each  successive  time  at  a  lower 
level.  The  stone  finally  passed  and  was  weighed  by  me.  As  stated,  it  weighed 
one  and  a  half  grains.  The  patient  suffered  no  further  discomfort.  He  was 
a  man  with  a  thick  abdomen,  but  of  short  stature.  His  weight  was  175 
pounds. 

The  stones  discovered  have  varied  from  a  fraction  of  a  grain  to  nearly  an 
ounce  in  weight.  They  have  all  either  contained  oxalate  of  lime  in  appre- 
ciable quantity  or  have  consisted  largely  of  phosphates.  Several  stones  ap- 
peared to  consist  of  uric  acid  merely,  but  chemical  analysis  showed  at  least 
ten  per  cent  of  oxalate  of  lime  in  every  instance. 

In  several  cases  no  picture  has  been  obtained  good  enough  for  a  diagnosis. 
The  failures  have  been  due  to: 


THE    DIAGNOSTIC    VALUE    OF    THE    X-EAYS  379 

1.  Great  thickness  of  the  body  of  the  patient. 

2.  Imperfect  working  of  the  electrical  apparatus. 

3.  Improper  handling  of  the  photographic  plate  in  the  dark  room. 

4.  Imperfect  photographic  plates. 

Among  the  cases  in  which  a  negative  diagnosis  has  been  made,  in  one  I 
failed  to  detect  the  presence  of  several  small  calculi  in  the  end  of  the  ureter. 
In  this  case  the  X-ray  plate  did  not  extend  far  enough  downward  to  include 
that  portion  of  the  ureter  in  which  the  stones  were  afterwards  felt  per 
vaginam. 

While  I  do  not  intend  to  enter  into  an  elaborate  description  of  the  apparatus 
and  the  technic  employed,  I  believe  that  a  general  view  of  the  methods,  the 
difficulties,  and  the  apparent  limitations  of  the  procedure  at  the  present  time 
may  not  be  devoid  of  interest. 

To  insure  success  in  the  radiography  of  kidney  stones,  the  following  con- 
ditions must  be  fulfilled : 

The  electrical  current  used  to  excite  the  tube  must  be  of  high  voltage  and 
of  considerable  amperage.  The  best  coils  and  large  static  machines  answer  this 
requirement  perfectly. 

The  X-ray  tube  used  must  permit  the  passage  of  such  a  current  continuously 
for  several  minutes  without  much  change  in  internal  resistance,  and  to  produce 
the  best  effects  this  should  be  true,  although  the  resistance  or  vacuum  of  the 
tube  is  relatively  low  at  the  start.  This  condition  is,  in  my  experience,  hard 
to  fulfill. 

A  tube  of  relatively  low  resistance  produces  rays  showing  upon  the  photo- 
graphic plate  slighter  differences  of  density  in  the  structures  through  which 
the  rays  are  passed,  but  as  the  result  of  the  passage  through  such  a  tube  of  a 
powerful  current,  the  tube  usually  becomes  heated  with  a  further  fall  of  re- 
sistance and  the  production  of  rays  of  inadequate  penetrative  power.  A  tube 
of  high  resistance  tends  to  preserve  its  vacuum  resistance  better,  but  the  X-rays 
given  off  from  a  tube  the  resistance  of  which  is  very  high  possess  the  pene- 
trative power  to  a  high  degree ;  they  penetrate  all  the  structures  of  the  body 
more  nearly  in  an  equal  manner,  and  thus  produce  radiographs  showing  but 
little  contrast  between  tissues  of  different  densities.  Such  pictures  are  what 
are  described  in  photography  as  "  flat "  negatives.  The  positive  and  negative 
value  of  such  a  picture  of  the  body  of  an  individual  supposed  to  be  suffering 
from  renal  calculus  is  not  great. 

In  order  to  establish  the  absence  of  stone  it  is  necessary,  as  has  already 
been  pointed  out  by  a  number  of  observers,  to  produce  a  negative  which  shall 
show  such  marked  contrasts  between  structures  varying  but  little  in  density 
that  even  the  smallest  calculus  will  cast  a  definite  shadow.  This  may  usually 
be  done  in  young  persons  and  in  slender  adults.  It  is,  on  the  other  hand, 
exceedingly  difficult  when  the  individuals  are  large  and  stout. 

I  have  been  unable  to  make  up  my  mind  as  to  the  exact  cause  of  this  diffi- 
culty.    Probably  pictures  of  fat  people  are  hard  to  obtain  for  several  reasons. 


380  THE   X-EAYS   IX   SURGICAL   DIAGNOSIS 

In  the  first  place,  the  actual  thickness  of  tissue  to  be  penetrated  is  much  greater, 
consequently  the  exposure  must  be  longer ;  moreover,  the  length  of  the  exposure 
must  be  still  further  increased,  because  it  is  dangerous  to  expose  the  skin  for 
a  long  period  to  the  action  of  the  rays  unless  a  considerable  interval  exists 
between  the  tube  and  the  skin — twelve  inches  at  least.  There  seems  to  be  some 
reason  to  believe  that  long  exposures  excite  in  the  tissues  themselves  secondary 
foci  of  X-rays,  which  affect  the  photographic  plate  and  produce  a  blurred  and 
indistinct  picture. 

The  thickness  of  the  fat  upon  the  buttocks  and  upon  the  back  raises  the 
skeleton  and  the  kidney  some  distance  away  from  the  underlying  photo- 
graphic plate.  A  further  blurring  and  want  of  detail  in  the  image  is 
thereby  produced.  This  is  notably  the  case  in  women  possessing  thick 
buttocks. 

The  movements  of  the  abdominal  walls  of  fat  persons  also  seem  to  produce 
a  clouded  appearance  on  the  photographic  plate,  as  well  as  the  respiratory 
movements  of  the  kidney  itself. 

I  have  succeeded  occasionally  in  producing  satisfactory  negatives  of  very 
stout  people.  The  conditions  were  as  follows :  The  tube  used  was  the  water- 
cooled  tube  devised  by  Dr.  E.  Griinmach  and  sold  by  the  Kny-Scheerer  Com- 
pany. It  has  always  happened  to  be  an  entirely  new  tube,  of  relatively  low 
resistance,  showing  a  brilliant  apple-green  fluorescence  and  illuminating  the 
fhioroscope  brilliantly,  and  producing  vivid  fluoroscopic  images  of  the  flesh  and 
bones  of  the  wrist  and  forearm.  Such  a  tube  will  produce  a  vivid  picture  of 
the  hand  on  the  screen  at  a  distance  of  many  feet,  and  the  tube  has  always 
possessed  the  peculiarity  that  its  resistance  fell  but  little  even  after  some  min- 
utes of  running  at  its  full  capacity. 

I  have  never  taken  a  successful  picture  of  a  kidney  stone  with  a  tube 
which  had  been  used  many  times,  or  with  one  which  had  become  coated  with 
the  purplish-black  film  which  forms  in  old  tubes.  My  best  pictures  have  been 
taken  with  the  Wehnelt  electrolytic  interrupter,  with  rather  a  heavy  platinum 
electrode  having  a  considerable  amount  of  platinum  exposed  in  the  acid,  thereby 
permitting  the  use  of  a  current  of  considerable  amperage  and  relatively  slow 
interruptions. 

The  exposures  for  large,  stout  people  have  varied  from  ten  to  fifteen  min- 
utes with  the  anticathode  about  thirty  inches  from  the  photographic  plate. 
For  thin  individuals  these  exposures  have  been  shortened  one  half. 

I  do  not  know  whether  my  failure  to  obtain  good  pictures  with  any  but 
new  tubes  is  due  to  a  defect  in  the  apparatus  used  or  not,  but  I  am  inclined 
to  think  that  such  is  the  case,  since  the  experience  of  others  does  not  entirely 
agree  with  my  own. 

This  may  depend  upon  the  fact  that  with  the  machine  I  used  a  discharge 
occasionally  occurs  through  the  tube  in  both  directions.  Hitherto  I  have  been 
unable  to  prevent  this  when  driving  the  tubes  to  their  fullest  capacity,  and  they 
are  soon  destroyed. 


THE   DIAGNOSTIC    VALUE   OF   THE   X-EAYS  381 

It  has  sometimes  happened  that  with  all  the  conditions  apparently  favorable, 
and  with  the  greatest  pains  in  technic,  the  pictures  have  been  utter  failures. 

Sometimes  I  have  been  able  to  account  for  such  failures  by  imperfections 
in  the  photographic  plate  or  in  the  technic  of  development,  and  sometimes  I 
have  not  been  able  to  explain  the  failure.  A  serious  handicap  has  been  also,  in 
these  cases,  the  necessity  of  taking  the  pictures  singly  and  at  rather  long  inter- 
vals, on  account  of  the  danger  of  burns  and  of  the  unwillingness  on  the  part 
of  the  patients  to  permit  a  number  of  exposures  to  be  made.  The  very  great 
expense  also  of  new  tubes  for  each  case  has  prevented  the  best  obtainable 
results. 

The  conclusions  I  have  been  able  to  draw  from  my  experience  are  as 
follows : 

The  positive  diagnosis  of  kidney  stone  by  the  X-rays  is  reliable  and  of 
great  practical  value. 

The  negative  diagnosis  of  kidney  stone  by  the  X-rays  is  reliable  and  valu- 
able up  to  a  certain  limit. 

If  pictures  of  a  proper  quality  are  obtained,  calculi  of  oxalate  of  lime  and 
phosphates  can  be  excluded.     Pure  uric-acid  calculi  cannot. 

Pictures  of  a  proper  quality  can  be  obtained  with  ease  in  children  and 
slender  adults  of  both  sexes. 

Such  pictures  can  usually  be  obtained  by  repeated  trials  in  well-nourished 
adults. 

When  patients  are  unusually  stout,  when  the  abdomen  is  very  thick  and  the 
buttocks  are  large,  the  conditions  are  extremely  difficult,  and  only  occasionally 
will  a  satisfactory  result  be  obtainable  with  the  present  form  of  apparatus. 

Biliary  Calculi. — A  few  successful  results  in  the  detection  of  biliary  calculi 
by  means  of  the  X-rays  have  been  reported  by  Dr.  Carl  Beck.  My  own  efforts 
in  this  direction  have  been  failures.  If  the  individual  were  slender  and  the 
calculi  numerous  or  large,  and  situated  in  the  gall-bladder,  it  would  seem  rea- 
sonable to  suppose  that  they  might  be  detected  in  some  cases  by  placing  the 
patient  on  his  stomach  with  the  plate  beneath  the  region  of  the  gall-bladder.  A 
tube  of  low  vacuum  should  be  used  in  order  to  show  the  slightest  differences  of 
density,  and  the  exposures  should  be  short,  for  fear  of  blotting  out  the  shadows 
of  the  stones  altogether. 

As  far  as  I  am  aware,  no  successful  efforts  have  been  made  to  detect  the 
presence  of  concretions  in  the  vermiform  appendix.  Lying,  as  it  does,  in 
the  iliac  fossa,  when  normally  placed  it  would  overlie,  in  the  picture,  a  dense 
mass  of  bone,  a  position  not  favorable  for  the  detection  of  slight  shadows. 

(/)  The  Injuries  Produced  by  the  Diagnostic  Use  of  the  X-rays  upon 
Patients  and  upon  X-ray  Operators 

During  the  earlier  years  of  the  diagnostic  use  of  the  X-rays  a  good  many 
serious  injuries  occurred  from  want  of  experience ;  at  present  improved  appa- 


382  THE   X-KAYS   IN   STTKGICAL   DIAGNOSIS 

ratus  have  so  shortened  the  duration  of  exposures  that  X-ray  burns  rarely  occur, 
except  as  the  result  of  the  therapeutic  use  of  the  rays,  and  among  those  who 
are  frequently  exposed  to  the  rays  for  long  periods.  The  shortest  single  ex- 
posure followed  by  a  burn  in  my  own  experience  lasted  seven  minutes  with  the 
tube  distant  twelve  inches  from  the  skin ;  a  moderate  dermatitis  followed  in  five 
days.  Several  burns  have  been  produced  by  exposures  aggregating  thirty  min- 
utes upon  the  same,  or  upon  successive  days,  but  none  of  these  were  severe. 
On  the  other  hand,  patients  have  been  exposed  for  therapeutic  purposes  for  ten 
minutes  daily  for  six  weeks,  with  the  tube  not  more  than  six  inches  from  the 
skin,  and  no  burn,  other  than  slight  tanning,  has  appeared.  There  is  probably 
a  personal  idiosyncrasy  which  renders  some  persons  more  susceptible  than 
others.  The  color  or  quality  of  the  skin  does  not  appear  to  bear  any  relation 
to  this  susceptibility.  It  is  generally  believed  that  tubes  of  low  resistance  and 
rays  of  low  penetrative  power  are  more  apt  to  produce  burns. 

Various  observers  have  asserted  that  burns  might  be  prevented  by  interpos- 
ing between  the  tube  and  the  skin  a  screen  composed  of  a  thin  sheet  of  metal 
— gold  leaf  spread  upon  wood  or  a  thin  sheet  of  aluminum ;  I  have  not  found 
that  the  use  of  these  screens  prevents  burns  absolutely,  although  I  believe  the 
danger  of  a  burn  is  somewhat  diminished.  Anointing  the  skin  with  lanolin 
or  vaselin  has  been  suggested  as  a  means  of  preventing  dermatitis ;  I  have 
not  found  them  effective  in  all  cases.  With  the  large  coils  and  tubes  in  use 
at  present,  and  with  exposures  lasting  from  a  few  seconds  to  two  minutes,  der- 
matitis is  scarcely  likely  to  follow.  Damage  suits  have  been  brought  against 
many  surgeons  to  recover  on  account  of  X-ray  burns  produced  during  radio- 
graphic exposures;  they  have  not  been  successful  in  any  instance  as  far  as  I 
am  aware.  It  has  been  generally  held  by  the  courts  that  if  the  plaintiff  knew 
that  a  burn  might  follow  the  exposure,  and  accepted  the  risk,  the  surgeon  could 
not  be  held  responsible.  It  is,  however,  wise  when  about  to  expose  a  patient 
to  the  X-rays  for  diagnostic  purposes  to  expressly  warn  him  in  the  presence  of 
witnesses  that  a  burn  may  follow.  An  agreement  in  writing  to  the  effect  that 
the  risk  is  accepted  by  the  patient  is  desirable;  such  an  agreement  might  not 
prevent  a  suit,  but  would,  doubtless,  go  far  to  invalidate  a  claim  for  damages. 
The  surgeon  should  avoid  making  repeated  exposures  upon  the  same  or  suc- 
cessive days,  and  in  any  case  when  the  aggregate  time  of  exposure  for  one  or 
more  pictures  is  five  minutes  or  more,  it  is  well  to  wait  ten  days  before  subject- 
ing the  patient  to  the  influence  of  the  rays  a  second  time.  These  remarks  do 
not  apply  to  the  therapeutic  use  of  the  rays,  since  frequent  exposures  are 
necessary,  and  the  danger  of  a  burn  is  generally  understood  and  accepted  by  the 
patient.  It  is  wise  during  all  exposures  to  protect  those  parts  of  the  body  not 
to  be  included  in  the  picture  by  thick  sheets  of  lead,  insulated  from  the  patient's 
skin  by  towels  or  the  like. 

X-ray  Burns. — The  irritating  and  destructive  effects  of  the  X-rays  upon  the 
tissues  vary  to  some  extent,  according  to  whether  the  individual  is  exposed  only 
a  few  times,  with  a  short  interval  between,  so  that  the  cumulative  effect  of  the 


THE   DIAGNOSTIC    VALUE   OF   THE   X-EAYS  383 

rays  produces  a  single  destructive  lesion,  or  whether,  on  the  other  hand,  the 
exposures  are  short,  very  numerous,  and  extend  over  a  long  period  of  time.  In 
the  former  category  belong  the  X-ray  burns  produced  in  patients ;  in  the  latter, 
the  injuries  suffered  by  surgeons  and  other  X-ray  operators  who  are  exposed 
to  the  rays  in  the  course  of  their  work  for  long  periods. 

Burns  After  Single  Exposures. — As  the  result  of  a  single  exposure  or 
of  several  exposures  at  short  intervals,  the  injurious  effects  of  the  rays  appear 
after  from  four  days  to  two  weeks  from  the  time  of  exposure.  In  the  mildest 
cases  the  patient  suffers  a  burning  pain  in  the  exposed  part;  the  skin  becomes 
reddened,  hot,  and  tender;  slight  vesication  may  appear  after  a  few  days.  The 
vesicles  are  minute  and  soon  dry,  forming  crusts.  The  hair  upon  the  part 
usually  falls  out.  At  the  end  of  ten  days  or  a  fortnight  the  burning,  redness, 
and  tenderness  gradually  subside,  and  although  the  patient  may  feel  a  little 
pain  for  a  week  or  more  longer,  the  injury  gets  well,  and  leaves  no  serious  effect 
behind  except  the  loss  of  hair,  and  in  some  cases  a  moderate  amount  of  brown- 
ish pigmentation  of  the  skin.  The  hair  grows  again  in  the  course  of  a  few 
months. 

If  the  injury  is  more  severe  the  patient  begins  to  suffer  intense  burning 
pain,  followed  shortly  by  a  well-defined  area  of  redness  and  exquisite  tender- 
ness. Large  vesicles  form  upon  the  surface,  and  the  reddened  area  assumes  a 
dark  purple  or  magenta  color.  The  vesicles  become  confluent,  their  contents 
become  cloudy,  and  within  a  week  or  ten  days  from  the  commencement  of  the 
symptoms  the  horny  layer  of  the  skin  separates  over  a  considerable  part  of 
the  burned  area,  leaving  behind  an  exceedingly  tender  raw  surface,  on  the  level 
with  the  surrounding  skin,  from  which  escapes  a  moderate  amount  of  thin 
watery  discharge.  The  raw  surface  is  bright  red  in  color,  becomes  covered  in  a 
few  hours  with  a  thin,  delicate,  soft  pellicle  or  scab.  If  this  pellicle  be  wiped 
away,  the  surface  beneath  bleeds  readily.  The  lesion  is  characterized  by  con- 
tinuous and  fairly  severe  pain,  by  exquisite  sensitiveness,  and  by  extreme  slow- 
ness of  the  healing  process.  The  epidermis  grows  in  from  the  edges.  Such  a 
raw  surface,  three  or  four  inches  in  diameter,  may  require  many  months  to 
heal.  The  scar  left  after  such  a  burn  may  remain  sensitive  and  painful  for 
some  time.  It  is  usually  white  in  color,  smooth,  occasionally  pigmented ;  telan- 
giectasis may  follow. 

Burns  of  a  more  severe  character  than  this,  as  the  result  of  the  diagnostic 
use  of  the  rays,  are  at  present  practically  unknown.  Soon  after  the  X-rays 
came  into  general  use  a  few  of  these  burns  were  produced.  The  early  symptoms 
were  those  just  described,  but  the  destruction  of  tissue  involved  the  entire 
thickness  of  the  skin  and  sometimes  the  deeper  tissues.  A  white,  tough,  and 
leathery  slough  was  gradually  formed  on  the  burned  area.  The  lesion  was  so 
horribly  painful  that  these  unfortunates  usually  acquired  the  morphin  habit. 
The  vitality  of  the  deeper  tissues  was  impaired,  so  that  no  sharp  line  of  demarca- 
tion formed  between  the  living  and  the  dead  tissues.  There  seemed  to  be  little 
or  no  tendency  for  the  dead  material  to  separate  itself  from  the  living,  and  if 


384  THE   X-RAYS   IN    SURGICAL  DIAGNOSIS 

removed  by  operation  an  unhealthy  raw  surface  was  left  behind,  which  some- 
times existed  for  months  without  any  apparent  sign  of  healing.  The  condition 
sometimes  lasted  for  years  without  much  betterment,  and  amputation  was  neces- 
sary in  several  instances ;  in  others  an  extensive  plastic  operation. 

Chronic  Disturbances  Produced  by  Frequent  Exposures  to  the 
X-rays. — The  chronic  effects  produced  by  frequent  exposures  to  the  rays  for 
long  periods  of  time  have  been  very  frequent  among  those  who  have  used  the 
X-rays  continuously,  and  have  failed  properly  to  avoid  the  unnecessary  expos- 
ure of  their  hands.  In  the  mildest  form  the  skin  upon  the  back  of  the  hands 
becomes  dry,  slightly  red,  and  scaly.  The  skin  loses  its  elasticity,  and  when 
pinched  up  upon  the  back  of  the  hand  feels  like  leather.  The  hair  falls.  The 
hands  have  a  somewhat  red  and  congested  appearance.  If  the  exposures  are 
discontinued  the  effects  gradually  pass  away,  and  entirely  disappear  in  a  few 
months.  If  the  individual  does  not  heed  this  warning,  the  nutrition  of  the 
skin  of  the  hand  suffers  profoundly.  The  nails  become  friable  and  their 
growth  is  interfered  with ;  the  free  edge  of  the  nail  breaks  off  and  leaves  the 
end  of  the  finger  exposed,  sometimes  quite  well  down  into  the  matrix.  The 
nails  are  thinned,  ridged,  and  furrowed  transversely.  Hard  nodules  form 
upon  the  knuckles,  become  fissured,  and  finally  develop  into  shallow,  sensitive, 
and  intractable  ulcers.  The  hands  look  blue  and  shriveled.  If  the  individual 
ceases  to  be  exposed,  the  condition  of  the  hands  may  return  to  normal  in  six 
months  or  a  year.  If  he  persists,  the  condition  grows  slowly  but  steadily 
worse ;  the  nutrition  of  all  the  structures  of  the  hand  suffers ;  the  ulcerations 
become  deeper  and  more  extensive ;  the  joints  may  be  invaded,  and  the  hand 
may  finally  become  so  crippled  as  to  be  useless. 

Epithelioma. — Epithelioma  has  developed  in  several  instances,  and  amputa- 
tion of  the  fingers,  and  even  of  the  upper  extremity,  has  become  necessary.  In 
some  cases  it  appears  that  the  nutrition  of  the  hand  is  permanently  affected, 
so  that  the  lesions  are  progressive  after  the  exposures  to  the  rays  have  ceased, 
and  this,  too,  when  the  apparent  severity  of  the  condition  was  slight.  Three 
deaths  have  been  reported  within  the  past  year  among  surgeons  and  X-ray 
operators  from  recurrent  epithelioma  following  amputation  for  the  relief  of  the 
conditions  above  described.  In  several  instances,  also,  epithelioma  of  the  face 
has  developed  during,  or  after,  the  X-ray  treatment  for  lupus. 

Azoospermia. — Azoospermia  is  said  to  be  a  constant  condition  among  those 
who  are  frequently  exposed  to  the  X-rays.  As  yet  it  is  not  definitely  known 
whether  or  not  the  condition,  once  produced,  is  permanent,  but  instances  are 
known  to  me  where  the  condition  has  endured  for  more  than  a  year.  Recent 
observation  has  shown  that  the  condition  is,  at  least  in  some  cases,  probably 
not  permanent.  The  condition  is  that  impotentia  generandi.  Potentia  coeundi 
is  preserved.  As  a  means  of  protection  against  the  rays  the  following  device  is 
in  use  at  present  in  the  Xew  York  Hospital:  A  partition  is  built  across  the 
X-ray  room  and  covered  with  heavy  sheet  lead.  In  the  partition  is  a  door,  also 
covered  with  lead,  except  for  a  small  window  of  lead  glass.     All  the  controlling 


THE   DIAGNOSTIC    VALUE    OF    THE   X-RAYS  385 

devices,  switches,  etc.,  arc  so  placed  that  the  X-ray  operator,  after  arranging  the 
patient,  the  tube,  etc.,  retires  behind  the  partition  and  controls  the  operation  of 
the  coil,  tube,  etc.,  entirely  protected  from  the  rays.  Through  the  window  he 
can  observe  the  patient,  the  appearance  of  the  tube,  etc.  It  has  been  found 
necessary  to  carry  the  lead  screen  quite  down  to  the  floor  and  up  to  the  ceiling, 
to  avoid  the  influence  of  diffused  or  secondary  rays. 


26 


CHAPTEE    XII 

INJURIES  AND   DISEASES  OF  THE   SCALP 

SUBCUTANEOUS    WOUNDS    OF    THE    SCALP 

Anatomical  Peculiarities. — The  injuries  of  the  scalp  may  "be  subcutaneous 
or  open  wounds.  The  characters  of  contusions  of  the  scalp  are  modified  hy  the 
anatomical  arrangement  of  the  several  layers  of  soft  parts  covering  the  skull. 
The  skin  is  firmly  attached  by  dense  bundles  of  connective  tissue  to  the  under- 
lying aponeurosis  of  the  occipito-frontalis  muscle  or  galea ;  hence,  subcutaneous 
effusions  of  blood  between  these  layers  form  circumscribed  swellings,  rather 
tense  and  prominent.  Such  constitute  the  familiar  bumps  on  the  head  seen 
so  often  in  children  after  blows  and  falls  upon  the  head.  On  the  forehead, 
in  the  temporal  regions,  and  near  the  occiput,  where  the  skin  rests  upon  the 
frontal,  temporal,  and  occipital  muscles,  the  union  between  the  skin  and  the 
underlying  structures  is  less  intimate  and  firm,  and  in  these  regions  blood  or 
other  fluid  beneath  the  skin  is  diffused  more  rapidly.  The  galea,  on  the  other 
hand,  is  but  loosely  attached  to  the  pericranium,  and  subaponeurotic  fluid  col- 
lections, whether  blood  or  pus,  tend  to  spread  widely.  The  swelling  produced 
is  neither  sharply  defined  nor  tense.  The  pericranium  is  attached  to  the  skull 
quite  firmly  along  the  sutures  and  at  the  sites  of  muscular  attachments ;  hence, 
accumulations  of  fluid  between  the  skull  and  its  periosteum  may  be  limited  to 
a  single  bone,  or  in  some  directions  by  a  tendinous  insertion.  These  limita- 
tions are  more  marked  in  adults  than  in  children.  In  children  the  vascu- 
lar connections  between  the  pericranium  and  the  skull  are  more  numerous, 
and  subpericranial  hematomata  are  very  rare  except  during  childhood  or 
infancy. 

Signs  of  Contusion  of  the  Scalp. — The  signs  of  contusion  of  the  scalp  vary, 
then,  according  to  the  anatomical  site  of  the  effused  blood ;  if  subcutaneous,  a 
sharply  defined  rounded  elevation  appears  immediately  after  the  injury.  The 
swelling  is  tense  and  elastic,  and  may  fluctuate;  if  grasped  in  the  fingers,  the 
mass  will  be  found  to  move  with  the  skin.  Immediately,  or  after  a  few  hours, 
a  characteristic  discoloration  of  the  skin  develops;  dark  blue  at  first.  After 
eighteen  to  twenty-four  hours  the  margin  of  the  ecchymotic  area  becomes  lighter 
in  color  and  of  a  violet  shade.  The  subsequent  color  changes  are  brown,  green, 
and  finally  yellow ;  the  lighter  colors  appearing  on  the  advancing  border  of 
discoloration  as  the  blood  pigment  is  diffused  through  the  tissues.  The  swell- 
386 


SUBCUTANEOUS    WOUNDS    OF    THE    SCALP  387 

ing  soon  disappears.  The  discoloration  remains  a  longer  or  shorter  time, 
according  to  the  amount  of  effused  blood  and  its  situation.  On  the  scalp,  fore- 
head, and  eyelids  it  is  usually  quite  gone  in  a  few  days ;  in  the  extremities,  on 
the  other  hand,  yellow  pigmentation  may  be  present  for  weeks.  If,  as  the  result 
of  a  contusion,  blood  accumulates  beneath  the  galea,  it  spreads  widely ;  the 
resulting  hematoma  may  cover  a  large  part  of  the  skull.  A  boggy  condition 
of  scalp  results  if  the  amount  of  blood  is  moderate ;  if  larger,  a  fluctuating, 
diffuse  swelling  of  but  little  tension  is  found.  Continued  bleeding  may  cause  the 
swelling  to  increase  in  size  and  extent  for  hours  or  days.  Rarely — an  artery 
of  some  size  being  torn— the  tumor  may  pulsate.  A  traumatic  aneurism  or 
arterial  hematoma  may  be  found  in  rare  instances,  and  arterio-venous  aneurism 
has  also  been  observed. 

Examination  of  Hematomata. — In  examining  hematomata  lying  beneath  the 
galea  the  following  peculiarities  are  to  be  borne  in  mind :  The  tissues  at  the 
border  of  the  hematoma  soon  become  infiltrated  with  blood,  and  later  with 
fibrin.  As  the  examining  finger  passes  across  this  border  and  depresses  the 
scalp  into  contact  with  the  skull,  the  bone  may  feel  as  though  depressed.  The 
true  condition  can  be  recognized  by  pressing  and  stroking  the  infiltrated  border 
of  the  hematoma ;  the  blood  clot  and  fibrin  are  thus  pressed  away,  and  the  sen- 
sation given  to  the  finger  of  a  depression  in  the  skull  disappears.  Usually  such 
hematomata  are  rapidly  absorbed  and  disappear  in  a  few  days ;  in  rare  cases  the 
fluctuating  tumor  may  remain  for  several  weeks.  The  introduction  of  an 
aspirating  needle  into  the  tumor  withdraws  partly  disintegrated  blood.  Con- 
tusions of  the  scalp  rarely  produce  a  subperiosteal  hematoma  in  adults.  The 
lesion  is  more  common  in  children,  and  the  effusion  is  often  limited  to  one  bone 
or  by  tendinous  insertions.  The  differential  diagnosis  from  subaponeurotic 
hematomata  is  not  easy. 

Associated  Lesions. — Hematomata  of  the  scalp  are  often  associated  with 
the  symptoms  of  Commotio  cerebri,  concussion  of  the  brain,  as  well  as  with 
fissured  fractures  of  the  vertex.  Definite  syn^toms  of  compression  or  laceration 
of  the  brain  are  not  present  unless  the  degree  of  violence  was  extreme.  While 
hematomata  of  the  scalp  rarely  require  operative  treatment,  they  may  become 
infected  through  abrasions  of  the  scalp  or  through  severely  contused  skin  areas 
which  become  necrotic.  The  surgeon  will  do  well,  therefore,  to  shave,  disin- 
fect, and  protect  the  overlying  skin.  When  infection  occurs  the  diagnosis 
becomes  that  of  abscess  or  phlegmon  of  the  scalp.  (See  Phlegmon  of  the 
Scalp. ) 

Edematous  Tumor  of  the  Scalp  in  the  New-born  (Caput  succedaneum). — 
During  labor  that  portion  of  the  presenting  head  not  subjected  to  the  uniform 
compression  of  the  parturient  canal  becomes  the  seat  of  edema  and  ecchymosis. 
During  the  earlier  part  of  labor,  the  edema  takes  place  in  that  portion  of  the 
scalp  encircled  by  the  border  of  the  cervix.  The  edematous  area  is  circular. 
During  the  delay  which  occurs  at  the  perineum  the  vulva  may  act  in  a  similar 
manner;  the  edematous  area  is  oval.     Two  such  areas  may  thus  exist  on  the 


388  INJURIES   AND  DISEASES   OF   THE   SCALP 

same  head.  If  the  membranes  have  remained  unbroken,  or  the  labor  has  been 
rapid,  the  tumor  will  be  small  or  absent ;  if  the  pelvis  is  contracted  or  the  labor 
long,  it  will  be  larger.  At  birth  the  scalp  will  be  swollen  and  edematous  over 
a  rounded  or  oval  area  whose  situation  varies.  In  left  occipitoanterior 
positions  the  tumor  forms  over  the  posterior-superior  angle  of  the  right  parietal 
bone.  In  right  occipito-anterior  cases,  over  the  corresponding  point  on  the  left 
side.  In  occipito-posterior  positions  the  tumor  will  be  over  the  anterior  angle 
of  that  parietal  bone  which  is  turned  toward  the  pubic  arch.  The  color  of  the 
tumor  is  dark  red  or  bluish  red  at  birth,  and  if  blood  is  extravasated  into  the 
tissues  goes  through  the  ordinary  ecchymotic  changes.  Disappearance  of  both 
tumor  and  discoloration  is  rapid,  and  occurs  after  a  few  days.  In  cases  where, 
owing  to  a  large  head  or  a  shortened  conjugate,  the  head  is  exposed  to  prolonged 
or  severe  pressure  from  the  promontory  of  the  sacrum,  oval,  rounded,  or  linear 
contusions,  abrasions,  and  excoriations  may  be  present  at  birth  on  that  portion 
of  the  fetal  head  exposed  to  pressure. 

Cephalhematomata  of  the  New-born. — Pressure  exerted  upon  the  fetal  head 
by  the  pelvic  walls  of  the  mother  during  labor  may  cause  lacerations  of  the 
blood-vessels  of  the  pericranium  along  the  lines  of  the  sutures,  and  stripping 
of  the  pericranium  from  the  bone.  Less  often,  the  vessels  beneath  the  galea 
are  torn.  Such  lesions  are  said  to  occur  once  in  two  hundred  labors.  Bending, 
or  actual  fracture,  of  the  cranial  bones  is  a  rare  concomitant  of  this  condition, 
and  may  be  associated  with  intracranial  hemorrhage.  As  the  result  of  sub- 
pericranial  bleeding  a  fluctuating  tumor  of  some  size  may  be  observed  at  birth 
or  after  a  few  hours — commonly  in  the  parietal  region.  They  are  to  be  differ- 
entiated from  encephalocele  from  the  fact  that  the  latter  occurs  in  the  middle 
line.  (See  Encephalocele.)  These  hematomata  soon  develop  the  following 
characters :  The  fluctuating  swelling  has  a  sharply  marked,  firm  border  above 
the  level  of  the  included  portion  of  skull,  which,  therefore,  feels  as  though 
depressed;  this  is  due  to  rapid  production  of  bone  tissue  by  the  pericranium 
along  the  border  of  the  swelling.  The  border  of  the  hematoma  is  thus  sur- 
rounded by  a  more  or  less  completely  ossified  bony  ridge.  The  blood  is  ab- 
sorbed in  ten  days  or  so,  and  the  pericranium  again  becomes  attached  to  the 
skull.  The  new  bone  may  also  disappear  in  time  or  remain  as  a  bony  ridge  or 
leave  behind  a  series  of  small  bony  projections  resembling  Wormian  bones 
on  palpation.  Infection  of  cephalhematomata  produces  the  signs  and  symptoms 
of  abscess,  phlegmon,  or  gangrene  of  the  scalp. 

Traumatic  Blood  Cyst. — The  regular  history  of  hematomata  of  the  scalp 
is  that  they  are  rapidly  absorbed  and  disappear.  Sometimes  absorption  does 
not  occur,  and  a  cavity  remains,  having  a  wall  of  connective  tissue  and  contain- 
ing a  reddish-yellow  more  or  less  turbid  or  clear  fluid.  The  history  of  an 
injury,  the  presence  of  a  circumscribed  fluctuating  noninflammatoiw  tumor 
upon  the  scalp,  and  the  character  of  the  fluid  contents,  as  determined  by  aspira- 
tion, establish  the  diagnosis. 


OPEN    WOUNDS    OF    THE    SCALP 


389 


OPEN    WOUNDS    OF    THE    SCALP 

Anatomical  Observations. — The  blood  supply  of  the  scalp  is  abundant.  Scalp 
wounds  usually  bleed  freely.  The  arterial  supply  of  the  scalp  is  as  follows : 
The  forehead  is  supplied  chiefly  by  the  frontal  and  supra-orbital  branches  of 
the  ophthalmic  artery.  The  supra-orbital  artery  emerges  from  the  orbit  at  the 
supra-orbital  foramen.  The  frontal 
artery  emerges  from  the  orbit  at  its 
inner  angle.  Laterally,  and  in  front 
as  well,  the  scalp  is  supplied  by  the 
anterior  and  posterior  branches  of  the 
temporal  artery.  The  main  trunk  of 
the  temporal  crosses  the  zygoma  just 
in  front  of  the  ear,  and  is  covered  at 
this  point  by  a  layer  of  fascia  derived 
from  the  parotid  gland.  It  may  be 
felt  pulsating  ^  to  1  cm.  in  front  of 
the  ear  over  the  zygoma.  Posteriorly, 
the  posterior-auricular  and  the  occip- 
ital arteries  furnish  the  blood  supply 
of  the  scalp.  The  occipital  artery 
pierces  the  cranial  attachment  of  the 
trapezius  muscle  and  becomes  super- 
ficial just  behind  the  mastoid  process 

— and  on  a  level  with  the  lobule  of  the  ear,  on  a  line  joining  the  external 
occipital  protuberance  with  the  tip  of  the  mastoid  process.  All  these  arteries 
anastomose  very  freely  in  and  beneath  the  skin. 

The  veins  of  the  scalp,  in  general,  follow  the  course  of  the  arteries.  They 
communicate  freely  with  the  veins  inside  the  skull.  The  frontal  and  supra- 
orbital veins,  with  the  ophthalmic;  the  occipital,  with  the  mastoid  vein.  The 
so-called  emissary  veins  are  also  numerous.  They  pass  through  the  skull  in 
an  oblique  direction,  and  often  communicate  with  the  veins  of  the  diploe.  Some 
of  them  are  small  venous  channels  passing  through  the  skull  at  or  near  the 
sagittal  suture.  These  channels  are  known  as  parietal  foramina ;  they  afford 
communication  between  the  superficial  veins  and  the  superior  longitudinal  sinus 
of  the  cranium.  A  vein  also  passes  through  the  foramen  cecum  of  the  frontal 
bone ;  it  unites  the  veins  of  the  nasal  fossae  with  the  superior  longitudinal  sinus. 
The  posterior  condyloid  foramina  transmit  veins  affording  communication 
between  the  veins  of  the  cranial  cavity  and  the  vertebral  veins,  as  well  as  the 
deep  veins  of  the  back  of  the  neck.  In  estimating  the  gravity  of  infectious 
processes  of  the  scalp  these  venous  channels  of  communication  must  be  borne 
in  mind. 

Wounds  of  the  scalp  may  be  incised,  contused  and  lacerated,  punctured,  or 
gunshot  wounds. 


.'■///' 
'J' 

Fig.  134. — Diagram  Illustrating  the  Arterial 
Supply  of  the  Face  and  Scalp. 


390  INJURIES   AND   DISEASES    OE   THE    SCALP 

Incised  Wounds. — Incised  wounds  are  those  made  by  sharp-cutting  instru- 
ments. They  are  linear  and  straight  or  curved  in  outline.  If  the  cutting 
instrument  strikes  the  head  in  a  more  or  less  tangential  direction  a  consid- 
erable flap  of  soft  parts  may  be  raised  from  the  skull  or  even  completely  cut 
away.  Such  wounds  may  be  made  by  a  saber  stroke.  Incised  wounds  divid- 
ing the  skin  merely,  gape  but  little,  though  they  bleed  quite  freely.  Wounds 
which  divide  the  galea  gape  notably.  In  the  frontal  and  occipital  regions 
transverse  wounds  gape  more  than  those  running  antero-posteriorly.  Bleeding 
from  even  a  small  wound  of  the  scalp  may  be  serious,  or  even  fatal,  if  un- 
checked. The  division  of  one  of  the  larger  arteries  is  readily  recognized  by 
the  rapid  escape  of  arterial  blood  in  jets  and  by  the  anatomical  site  of  the 
wound. 

Contused  and  Lacerated  Wounds  of  the  Scalp. — Contused  and  lacerated 
wounds  of  the  scalp  are  much  more  common  as  accidental  wounds  than  clean 
cuts.  They  are  caused  by  blows  upon  the  head  with  blunt  objects — clubs  or 
stones  and  the  like — or  by  falls  upon  the  head  against  hard,  rough,  or  angular 
bodies.  They  are  sometimes  produced  by  sudden  violent  traction  upon  the 
scalp — as  when  a  woman's  hair  is  caught  in  moving  machinery.  Explosions  of 
gunpowder,  dynamite,  and  gun-cotton  produce  extensive  contused  and  lacerated 
wounds  of  the  scalp.  When  the  blow  falls  at  right  angles  to  the  surface  of  the 
skull,  the  wound  is  often  linear,  and  may,  at  the  first  glance,  resemble  an 
incised  wound;  close  inspection  will  show  contusion,  fraying,  and  irregularity 
of  the  wound  edges,  or  contusions  and  abrasions  in  the  vicinity.  Often  the 
wound  edges  will  be  found  infiltrated  with  blood,  or  pockets  containing  blood 
clot  will  be  present.  In  some  cases  when  a  single  blow  has  been  struck  by  a 
sharp  stone  or  a  smooth  club — and  notably  if  it  has  fallen  upon  a  bony  ridge — 
the  wounds  may  very  closely  resemble  incised  wounds,  and  the  surgeon  should 
exercise  due  caution  if  called  upon  to  testify  that  a  certain  wound  has  been 
made  by  a  sharp  or  by  a  blunt  object,  as  the  case  may  be. 

When  the  force  meets  the  skull  obliquely,  or  nearly  tangentially,  the  scalp 
may  be  extensively  torn ;  thus,  angular,  rounded,  or  irregular  flaps  of  scalp 
may  be  stripped  up,  and  even  completely  separated  from  the  head.  Violent 
traction  upon  the  hair  by  machinery  may  tear  the  entire  scalp  from  the  head. 
When  a  flap  is  created,  the  part  of  the  wound  where  the  violence  was  first 
applied  will  be  contused,  frayed,  or  completely  crushed  and  shredded.  The 
tears  caused  by  stripping  and  traction  upon  the  scalp  are  usually  linear,  and 
resemble  clean  cuts.  The  flaps  usually  include  the  skin  and  the  galea,  but  if 
the  pericranium  was  penetrated  by  the  direct  violence  of  the  blow  or  fall,  it 
may  also  be  included  more  or  less  extensively  in  the  flap. 

Injuries  to  the  Scaep  caused  by  Explosions. — The  injuries  to  the  scalp 
caused  by  explosions  are  sometimes  remarkable.  I  recall  a  case  seen  at  Bellevue 
Hospital,  when  I  was  house  surgeon  there,  of  this  character.  A  dynamite 
cartridge  exploded  among  some  workmen,  who  were  thawing  it  out  over  a  fire. 
Several  of  them  were  killed  outright ;  one  of  them  was  brought  living  to  the 


OPEN   WOUNDS    OF    THE    SCALP  391 

hospital.  Among  his  injuries  was  a  wound  which  extended  from  ear  to  ear 
across  the  front  of  his  face ;  a  flap  was  thus  created,  including  his  upper  eye- 
lids, the  upper  half  of  his  nose,  and  his  forehead.  This  flap  was  raised  and 
stripped  back  from  his  skull  as  far  as  his  ears;  the  flap  was  everywhere  filled 
with  little  stones  and  splinters  of  wood ;  many  stones  were  embedded  in  his  skull. 
His  eyes  were  destroyed.  Several  hundred  stones  and  splinters  were  removed 
from  this  dreadful  wound  and  from  his  chest  and  arms.  One  wooden  splinter, 
six  inches  long,  entered  his  right  forearm  at  its  middle,  and  was  removed  from 
his  upper  arm  near  the  shoulder.  He  survived,  although  blind  and  much 
disfigured. 

Punctured  Wounds  of  the  Scalp. — Punctured  wounds  of  the  scalp  occur  for 
the  most  part  as  the  result  of  stabs  with  knives,  daggers,  and  the  like ;  they 
may  extend  beneath  the  scalp  for  a  considerable  distance,  and  are  often  accom- 
panied by  injuries  of  the  skull.  A  stab  downward  in  the  temporal  region  may 
pass  to  the  inner  side  of  the  zygoma,  and  thus  wound  the  deep  temporal  artery, 
giving  rise  to  serious  bleeding,  and  possibly  rendering  a  ligature  of  the  external 
carotid  artery  necessary. 

Gunshot  Wounds  of  the  Scalp. — Wounds  of  the  head  made  by  rifle  bullets 
and  by  shotguns  fired  at  close  range,  or  by  portions  of  shell  or  other  heavy  projec- 
tiles fired  in  battle,  are  quite  commonly  immediately  fatal,  involving,  as  they 
often  do,  injuries  to  skull  and  brain  of  a  destructive  character.  Wounds  in- 
volving the  scalp  merely  will  usually  have  been  made  by  revolvers  of  small 
caliber  and  low  velocity,  or  by  spent  balls  from  rifles,  or  by  small  shot  fired 
from  a  shotgun  at  a  considerable  distance.  These  wounds  present  three  com- 
mon types : 

1.  The  bullet  strikes  the  head  squarely,  but  is  of  small  size,  is  composed  of 
soft  lead  driven  at  a  low  velocity,  and  flattens  against  the  skull  not  far  from 
the  wound  of  entrance. 

2.  The  bullet  cuts  a  mere  groove  in  the  scalp,  following  more  or  less  the 
contour  of  the  skull  for  some  distance. 

3.  The  bullet  enters  the  scalp  and  cuts  a  canal  of  considerable  length  be- 
tween the  galea  and  the  skull,  passing  out  again  at  a  somewhat  distant  point, 
or  lodging.  In  a  wound  of  this  last  kind  the  bullet  may  be  so  deflected  from 
its  course  by  the  skull,  on  the  one  hand,  and  by  the  dense  aponeurosis  on  the 
other,  that  its  path  may  partly  encircle  the  head,  so  that  the  wound  of  exit  may 
be  nearly  or  quite  opposite  to  the  wound  of  entrance,  creating  an  inference  that 
the  bullet  has  passed  through  the  skull  and  the  cranial  cavity.  The  absence  of 
a  hole  in  the  skull  and  of  symptoms  of  injury  to  the  brain  will  usually  prevent 
this  erroneous  conclusion. 

Bird-shot  Wounds. — Wounds  made  by  bird  shot  vary  much  in  character, 
according  to  the  range  at  which  the  shot  was  fired.  If  the  range  is  short,  and 
the  load  strikes  the  head  or  any  portion  of  the  body  squarely,  a  large  ragged 
hole  is  produced  with  great  destruction  of  tissue.  The  distance  at  which  such 
an  injury  will  be  produced  depends  upon  the  size  and  boring  of  the  gun  rather 


392  INJURIES   AND   DISEASES    OF   THE   SCALP 

than  upon  the  size  of  the  shot  used,  since — for  a  distance  sometimes  exceeding 
twenty  feet — the  effect  produced  by  the  shot  traveling  en  masse,  or  but  little 
separated,  is  that  of  a  single  large  missile.  For  example,  a  man  was  acci- 
dentally shot  in  the  loin  by  his  companion.  The  gun  was  a  twelve-gauge  shot- 
gun loaded  with  the  usual  charge  of  smokeless  powder  and  an  ounce  and  an 
eighth  of  No.  8  shot ;  the  range  is  said  to  have  been  twenty  feet.  A  large  hole 
was  torn  in  the  loin  behind,  and  a  still  larger  hole  at  the  point  of  exit  in  front, 
through  which  coils  of  torn  intestine  protruded.  At  greater  ranges  the  wounds 
made  by  the  pellets  are  discrete,  and  the  penetration  varies  with  the  range  and 
the  size  of  the  pellets.  (See  chapter  on  Gunshot  Wounds.)  Shotgun  wounds 
of  the  head  may  be  followed  by  fatal  results,  even  when  the  range  is  consider- 
able and  the  pellets  small  in  size.  For  example,  in  a  case  reported  by  Dr. 
Lewis  Stimson  a  single  pellet  of  No.  7  shot  entered  a  thin  portion  of  the  frontal 
bone  just  below  the  inner  end  of  the  eyebrow  and  produced  a  fatal  injury  of 
the  brain. 

Examination  of  Wounds  in  Diagnosis. — The  examination  of  wounds  for 
diagnostic  purposes  should  be  made  with  painstaking  observance  of  the  rules 
of  asepsis.  When  it  is  remembered  that  the  most  trifling  wound  of  this  region 
may  result  fatally  from  erysipelas  or  intracranial  suppuration,  the  weight  of 
this  caution  becomes  clear.  Scrubbing  and  shaving  the  scalp  over  a  considerable 
area  should  precede  any  exploration.  Rubber  gloves  should  be  worn,  and  every 
possible  effort  should  be  made  to  avoid  contamination,  whether  the  wound  be 
already  infected  or  not.  The  important  points  to  be  remembered  are:  Does 
the  wound  divide  merely  the  skin,  or  is  the  galea  also  divided  ?  Is  the  peri- 
cranium separated  from  the  skull  %  Is  the  skull  itself  injured  ?  Is  any  impor- 
tant vessel  divided  or  a  nerve  trunk  ?  Is  a  foreign  body  present  in  the  wound 
— a  portion  of  the  instrument  which  produced  the  wound,  or  hair,  or  dirt,  or 
gravel,  or  a  bullet,  etc.  ?  Are  the  edges  of  the  wound  contused  to  such  an  extent 
that  their  vitality  is  lost  or  imperiled  ?  Is  the  wound  infected,  and  to  what 
extent  ? 

Does  the  Wound  Divide  Merely  the  Skin,  or  is  the  Galea  also 
Divided  ?  Is  the  Pericranium  Separated  from  the  Skull  ?  Is  the 
Skull  Itself  Injured  ? — The  depth  and  extent  of  incised  and  of  contused 
and  lacerated  wounds  is  often  apparent  at  the  first  glance  after  the  wound 
has  been  wiped  clean  of  blood,  foreign  material,  or  pus,  as  the  case  may  be,  and 
yet  this  is  not  always  so.  If  the  wound  is  small,  it  may  be  impossible  to  see 
whether  the  injury  involves  the  skull  or  not.  We  then  have  recourse  to  the 
use  of  a  sterile  instrument,  a  probe,  the  handle  of  a  scalpel,  or  the  like,  or  a 
finger  properly  protected  by  a  sterile  glove.  We  may  then  at  once  discover  by  the 
presence  or  absence  of  a  grating  sensation  transmitted  to  the  hand  whether 
the  skull  is  exposed,  and  often  whether  the  surface  of  the  skull  is  smooth,  or 
whether,  on  the  other  hand,  an  abrupt  ridge  is  present,  indicating  a  fracture. 
We  may  be  misled  in  certain  cases ;  when  the  pericranium  is  stripped  up  from 
the  skull,  the  instrument  may  rise  suddenly  from  the  denuded  bone  upon  the 


OPEN   WOUNDS    OF   THE    SCALP  393 

stripped-up  pericranium  to  a  higher  level,  and  thus  the  sensation  of  a  slightly 
depressed  fracture  along  the  line  of  the  stripped-up  periosteum  may  be  very 
distinct.  If  unable  to  decide  positively,  we  enlarge  the  wound  and  verify  the 
condition  by  direct  vision. 

Is  Any  Important  Vessel  Divided,  or  a  Xerve  Trunk? — Any  consider- 
able blood-vessel,  if  divided,  will  usually  make  itself  evident,  either  at  once, 
or  during  the  cleansing  operations,  if  the  wound  be  recent.  The  main  trunk 
and  two  principal  branches  of  the  deep  temporal  are  so  inaccessible  that  liga- 
ture of  the  external  carotid  is  preferable  to  an  attempt  to  ligate  the  wounded 
vessel  itself.  The  division  of  the  supra-orbital  nerve,  and  its  subsequent  inclu- 
sion in  a  scar,  may  give  rise  to  neuralgia. 

Is  a  Foreign  Body  Present  in  the  Wound  ? — Foreign  bodies  are  to  be 
searched  for  in  contused  and  lacerated  wounds,  but  more  especially  in  punc- 
tured wounds — such  as  are  caused  by  a  stab  with  a  penknife  or  the  like.  Such 
instruments  are  usually  capable  of  infecting  a  wound,  and  if  their  presence 
is  probable,  careful  search,  enlarging  the  wound,  if  necessary,  is  desirable,  not 
only  for  their  extraction,  but  to  exclude  perforation  of  the  skull.  Gunshot 
wounds,  on  the  other  hand,  do  not  necessarily  demand  search  for,  and  extrac- 
tion of,  the  bullet,  if  this  is  known  to  be  lodged.  In  case  the  site  of  the  bullet 
can  be  seen  or  felt  through  the  skin,  removal  is  proper ;  but  indiscriminate  prob- 
ing is  unwise  and  unnecessary.  If  the  skin  orifice  is  cleaned,  these  wounds 
often  heal  per  primam.  The  site  of  any  metallic  foreign  body  embedded  in 
the  scalp  can  sometimes  be  appreciated  by  the  use  of  the  fluoroscope,  and  usu- 
ally by  means  of  a  radiograph.     (See  the  Use  of  X-rays  in  Surgical  Diagnosis.) 

To  What  Extent  is  the  Vitality  of  the  Wound  Edges  Imperiled? 
— The  scalp  is  so  abundantly  supplied  with  blood  that  even  flaps  which  appear 
to  be  much  contused,  and  whose  living  connections  are  small,  may  still  be 
expected  to  survive,  either  entirely  or  in  part.  Accordingly,  too  hasty  a  judg- 
ment should  not  be  formed,  since,  under  careful  asepsis,  nothing  will  be  lost 
by  waiting  for  actually  dead  tissue  to  distinguish  itself  from  the  living. 

Is  Infection  Present  in  the  Wound,  and  to  What  Extent  ? — While 
nearly  every  accidental  wound  of  the  scalp  may  be  regarded  as  a  possibly 
infected  wound,  and  be  treated  accordingly,  we  now  refer  especially  to  wounds 
in  which  infection  of  one  sort  or  another  is  already  present.  The  scalp  should 
be  shaved  over  a  large  area  surrounding  the  wound  in  order  to  make  a  proper 
examination.  If  infected,  usually  a  boggy  edematous  condition  of  the  scalp 
will  be  noted,  and  the  size  of  this  area  is  often  a  fair  index  of  the  extent  of 
the  infection.  Redness  of  the  skin  is  not  marked  unless  erysipelas  is  present. 
The  wound  surface  will  be  found  covered  with  pale  granulations  or  with  slough- 
ing tissue ;  the  edges  will  often  be  slightly  everted ;  a  purulent  exudate  will 
usually  be  evident  upon  pressing  the  scalp  near  the  wound;  its  absence  does 
not  preclude  infection.  If  the  wound  has  penetrated  the  galea  the  exudate  is 
often  confined  beneath  this  layer,  and  exploration  of  the  wound  with  an  instru- 
ment or  a  gloved  finger  may  be  necessary  to  detect  its  presence.     Should  the 


394  INJURIES    AND   DISEASES    OE   THE    SCALP 

amount  of  purulent  discharge  seem  excessive  for  the  size  of  the  wound,  such 
an  accumulation  is  probably  present,  and  incisions  in  the  scalp,  often  of  large 
size,  will  be  necessary  to  determine  its  extent  and  provide  for  proper  drainage. 
If  infection  has  extended  beneath  the  pericranium,  the  pus  will  be  found  be- 
neath this  layer  and  bare  bone  will  be  seen  and  felt.  If  the  skull  itself  is  the 
seat  of  pyogenic  infection,  the  bone  will  appear  of  a  yellowish-green  color. 

If  the  infection  is  extensive,  or  of  a  severe  type,  constitutional  symptoms 
will  be  present — headache,  a  rise  of  temperature,  prostration,"  anorexia,  and  a 
leucocytosis  of  greater  or  less  intensity.  Inasmuch  as  the  spread  of  purulent 
infection  in  the  deeper  layers  of  the  scalp  is  often  of  an  insidious  character, 
and  its  results  disastrous — including  not  only  extensive  necrosis  of  the  galea, 
but  also  infection  of  the  skull  itself,  and  of  the  sinuses  and  meninges  of  the 
brain,  leading  to  fatal  pyemia  or  meningitis — no  pains  should  be  spared  on 
the  part  of  the  surgeon  to  render  his  diagnosis  complete  at  once;  if  necessary, 
by  the  administration  of  an  anesthetic  and  exploration  through  proper  incisions. 

DISEASES    OF    THE    SCALP 

Erysipelas  of  the  Scalp. — Wounds  of  the  scalp  appear  to  be  peculiarly  liable 
to  erysipelatous  infection.  The  region  is  one  not  commonly  kept  as  clean  as 
the  rest  of  the  person,  and  the  hair  harbors  many  bacteria  very  difficult  to 
remove  by  ordinary  means.  The  point  of  inoculation  is  in  many  instances  a 
wound  of  the  scalp  itself,  and,  in  perhaps  a  still  larger  number  of 
cases,  the  disease  begins  in  a  wound  of  the  face,  the  scalp  becoming 
involved  by  the  extension  of  the  process.  Ulcers  upon  the  face  or  in 
the  nasal  fossa?,  or  suppurative  processes  in  the  antrum  or  frontal  sinus,  are 
not  uncommon  sites  of  infection.  The  infection  may  take  place  in  a  mere 
abrasion,  or  in  a  wound  of  any  size  during  any  stage  of  the  healing  process, 
or  in  a  wound  already  infected  with  pyogenic  microbes.  If  a  clean  granulat- 
ing wound  be  present,  the  healing  process  may  be  but  little  affected  by  the  new 
infection;  or,  on  the  other  hand,  the  wound  surface  may  become  covered  by  a 
diphtheritic-looking  membrane  or  become  gangrenous.  In  a  suppurating  wound 
infected  with  erysipelas  the  amount  of  purulent  exudate  will  often  be  notably 
diminished.  Very  often  constitutional  symptoms  will  precede  the  local  signs 
some  hours  or  a  day.  There  will  often  be  a  sharp  chill,  followed  by  a  rise  of 
temperature,  headache  and  prostration,  a  coated  tongue.  Discomfort  in  the 
stomach,  and  even  vomiting,  are  not  uncommon  prodromal  symptoms.  Leuco- 
cytosis, with  relative  increase  in  the  polymorpho-nuclear  cells,  is  regularly  pres- 
ent. When  the  local  lesion  appears,  the  affected  portion  of  the  scalp  will  be 
red,  swollen,  and  edematous;  the  borders  of  the  red  area  will  be  sharply  cir- 
cumscribed from  the  surrounding  skin,  but  blisters  usually  do  not  form,  as 
they  do  upon  the  face.  The  subjective  symptoms  of  burning  and  itching  are 
present. 

In  some  severe  cases  of  erysipelas  of  the  scalp  it  is  desirable  that  the  entire 


DISEASES    OF   THE    SCALP  395 

scalp  should  be  shaved  ;  in  this  manner-  alone  can  the  progress  of  the  disease  be 
watched  intelligently,  and  the  complications  recognized  and  met,  if  they  occur. 
Subcutaneous  abscesses — if  such  occur — can  be  noted  at  once  and  incised :  and 
deep-seated  so-called  phlegmonous  areas  of  suppuration  and  necrosis  of  the  deep 
layers  of  the  scalp  are  less  likely  to  pass  unrecognized  in  their  early  stages,  as 
well  as  the  dusky  patches  on  the  skin,  which  indicate  perforation  by  the  deeper- 
seated  foci  of  suppuration. 

The  so-called  head  symptoms,  accompanying  erysipelas  in  this  region,  are 
often  the  cause  of  the  gravest  anxiety.  Headache,  delirium,  and  stupor,  fol- 
lowed in  bad  cases  by  coma,  are  often  observed.  In  some  of  the  more  severe 
cases  these  symptoms  are  marked,  and  yet  the  patients  recover.  It  is  not  always 
possible  in  a  given  case  to  say  during  the  progress  of  the  disease  whether  the 
threatening  symptoms  are  due  merely  to  the  severity  of  the  constitutional  poi- 
soning, or  to  a  septic  thrombophlebitis  of  the  sinuses  of  the  brain,  or  to  menin- 
gitis. The  occurrence  of  vomiting,  convulsions,  of  ocular,  or  other  palsies, 
and  later,  of  deep  coma,  point  to  an  intracranial  invasion.  Erysipelatous  infec- 
tion of  the  tissues  of  the  orbit  is  not  infrequently  complicated  with  invasion 
of  the  ophthalmic  vein,  and  so  of  the  sinuses  of  the  skull.  In  the  cases  com- 
plicated by  intracranial  suppuration  the  avenue  of  infection  may  be  through 
one  or  other  set  of  emissary  veins,  or  through  the  lymphatics,  or  along  the 
sheaths  of  the  cranial  nerves.  The  intracranial  process  may  consist  of  puru- 
lent thrombophlebitis  of  the  venous  sinuses,  followed  sometimes  by  pyemia ; 
or  of  meningitis.  (See  Diseases  of  the  Brain  and  its  Adnexa.)  The  occur- 
rence of  furious  delirium  in  the  course  of  erysipelas  of  the  scalp  is  not  uncom- 
mon among  chronic  alcoholics. 

Subcutaneous  Abscesses  of  the  Hairy  Scalp. — The  subcutaneous  abscesses  of 
the  hairy  scalp,  whether  occurring  as  a  complication  of  erysipelas  or  from 
other  causes,  are  to  be  recognized — as  are  similar  lesions  elsewhere — namely, 
by  the  formation  of  a  painful,  tender,  red,  circumscribed  swelling,  showing  in 
its  later  stages  the  sign  known  as  fluctuation,  giving  the  sensation  of  elastic 
tension  to  the  examining  fingers.  The  deep-seated  phlegmonous  inflammations 
of  the  scalp,  involving  the  galea  or  the  pericranium,  or  both,  are  sometimes 
less  easily  recognized  than  superficial  abscesses.  Shaving  the  scalp  facilitates 
the  examination  greatly.  A  boggy  edematous  condition  of  the  scalp,  often 
without  redness  of  the  skin,  will  be  found  upon  examination.  Tenderness  may 
be  marked,  but  in  some  of  the  more  severe  necrotic  inflammations  may  be  slight. 
Fluctuation  may  be  present,  obscure,  or  absent.  The  general  symptoms  are 
headache,  a  septic  temperature,  a  rapid,  and  later  a  feeble  pulse.  Death 
may  occur  from  the  severity  of  the  septic  poisoning  or  from  invasion  of  the 
interior  of  the  cranium. 

Upon  incision  the  galea  may  be  more  or  less  completely  necrotic,  and  the 
loose  connective  tissue  beneath  may  be  found  infiltrated  with  pus,  or  a  large 
cavity  or  a  series  of  cavities  filled  with  pus  may  exist  beneath  the  aponeurosis. 
If  unrelieved  by  incision,  a  large  portion  of  the  scalp  may  be  lifted  from  the 


396  INJURIES   AND   DISEASES    OF   THE   SCALP 

skull,  forming  a  loosely  fluctuating  sac  filled  with  masses  of  necrotic  tissue 
and  pus.  Gangrenous  perforation  or  sloughing  of  the  skin  may  occur  at  vari- 
ous points,  and  the  pus  may  burrow  deeply  into  the  neck  along  the  intermus- 
cular planes  or  into  the  temporo-maxillary  fossa.  In  some  cases  putrid  decom- 
position of  the  tissues  takes  place,  and  infection  with  gasogenic  bacteria  will 
be  accompanied  by  an  emphysematous  condition  of  the  tissues,  recognizable  by 
a  peculiar  elastic  consistence  and  by  crepitation  on  palpation  and  by  the  escape 
of  bubbles  of  gas  mixed  with  thin  purulent  fluid  when  the  incised  tissues 
are  conrpressed.  (See  Bacteria  of  Surgical  Infections.)  The  course  of  the 
more  severe  types  of  these  processes  is  sometimes  terribly  rapid,  and  death 
may  occur  very  early,  with  the  symptoms  of  profound  intoxication — headache, 
delirium,  stupor,  coma,  a  feeble  pulse,  a  high  temperature,  rapidly  ending  in 
collapse.  The  degree  of  leucocytosis  will  vary.  If  the  tissues  have  time  to 
react  after  the  invasion  of  the  bacteria,  leucocytosis  will  often  be  marked,  but 
in  the  most  rapidly  fatal  cases  this  sign  may  be  absent. 

Malignant  Pustule  or  Anthrax. — The  malignant  pustule  or  anthrax  is  not 
very  common  upon  the  hairy  scalp.     (See  Anthrax.) 

Eczema  of  the  Scalp. — This  disease  occurs  in  an  acute  form  upon  the  heads 
of  neglected  infants  and  young  children.  The  dried  exudate  from  the  inflamed 
skin  collects  in  thick  crusts,  cementing  the  hair  into  a  firm  mass  over  consid- 
erable areas.  After  the  crusts  are  removed,  the  red,  moist  surface  of  the  skin 
is  scarcely  to  be  confounded  with  other  conditions.  Before  the  skin  can  be 
properly  exposed  for  observation  and  treatment,  it  is  often  necessary  to  soften 
the  crusts  with  olive  oil  or  the  like,  and  to  cut  away  the  hair.  In  older 
children  eczema  of  the  scalp  is  often  the  result  of  the  presence  of  pediculi. 
Continued  scratching  with  infected  finger  nails  gives  rise  first  to  an  eczema, 
and  later  to  pyogenic  infection  with  the  production  of  subcutaneous  abscess 
behind  the  ears  and  along  the  border  of  the  hair  at  the  back  of  the  neck.  The 
recognition  of  the  nits  or  ova  of  the  pediculi  attached  to  the  shafts  of  the  hairs 
is  easy,  and  clears  up  the  cause  of  the  trouble  at  once.  The  ova  are  small 
ovoid-shaped  bodies  of  a  dirty-white  or  brownish-white  color  attached  to  the 
shafts  of  the  hairs  by  a  cement  furnished  by  the  female  louse.  The  lymphatic 
glands  of  the  neck  are  often  enlarged  and  tender,  and  sometimes  suppurate. 
An  interesting  sign  of  the  nervous  irritation  produced  by  these  parasites  is 
observed  in  many  cases — namely,  a  typical  torticollis  or  wry-neck,  attended 
by  tonic  rigidity  of  one  sternomastoid  muscle.  Removal  of  the  parasites  and 
of  the  eczema  by  cutting  the  hair,  and  appropriate  local  applications,  is  fol- 
lowed by  speedy  improvement  and  cure  of  the  wry-neck. 

Furuncles. — Furuncles  do  not  ordinarily  occur  upon  the  hairy  scalp,  but 
a  favorite  location  for  them  is  upon  the  back  of  the  neck  at  the  junction  of  the 
hair  with  the  naked  skin.  These  infections  of  the  hair  follicles  begin  as  a 
minute,  tender,  inflamed,  red,  swollen  area  in  the  skin,  resembling  an  acne 
pustule,  in  the  course  of  a  few  days  the  inflamed  area  is  very  red  and  hot. 
In  the  center  of  the  conical  swelling  can  usually  be  seen  a  yellow  point  cov- 


DISEASES    OF   THE    SCALP  397 

erecl  by  the  thinned-ont  horny  layer  of  the  skin,  representing  the  orifice  of  the 
affected  hair  follicle.  If  punctured,  or  allowed  to  rupture,  several  drops  of 
pus  escape,  followed  by  a  minute  slough ;  a  craterlike  opening  in  the  center 
is  left  in  the  skin  with  sloughy  walls.  Under  appropriate  surgical  incision 
and  disinfection  the  discomfort  is  speedily  lessened  and  the  disease  shortened. 
The  microbes  concerned  in  the  production  of  furuncles  are  usually  Staphylo- 
coccus aureus  and  albus,  and  the  same  is  true  of  carbuncle.  The  presence  of 
numerous  furuncles  usually  indicates  a  depressed  state  of  general  health.  The 
patient  should  be  carefully  examined  for  causes  of  such  depression.  Such  a 
cause  may  be  diabetes,  slow  or  imperfect  convalescence  from  acute  diseases 
(typhoid  fever,  for  example),  alcoholism,  uncleanly  habits,  etc. 

Carbuncle. — Carbuncle  does  not  ordinarily  occur  upon  the  hairy  scalp ;  the 
common  site  is  the  back  of  the  neck,  and  the  process  often  invades  the  scalp 
as  high  as  the  level  of  the  ears.  The  disease  may  be  regarded  as  a  congeries 
of  furuncles,  but  the  necrotic  inflammation  extends  into  the  subcutaneous  tis- 
sues as  deeply  as  the  surface  of  the  muscles,  and  in  bad  cases  may  involve  the 
intermuscular  planes.  The  recognition  of  carbuncle  is  easy.  A  painful,  ten- 
der, hard,  and  brawny  swelling,  usually  rounded  or  conical  in  contour,  occupies 
the  back  of  the  neck.  The  size  of  the  affected  area  varies ;  it  may  extend  from 
ear  to  ear.  The  skin  is  at  first  red,  later  purple,  and  finally  is  perforated  over 
small  areas;  here  and  there,  through  these  apertures,  pus  and  fragments  of 
broken-down  tissue  escape.  If  untreated,  the  entire  mass  of  necrotic  skin  and 
connective  tissue  may  be  cast  off,  leaving  a  deep,  undermined,  ragged  cavity 
lined  with  sloughing  connective  tissue.  Under  less  favorable  conditions  the 
disease  may  extend  downward  into  the  subcutaneous  tissues  of  the  back,  and 
that  without  showing  much  evidence  of  its  progress  in  the  overlying  skin.  Car- 
buncle is  a  disease  of  depressed  states  of  vitality.  It  is  common  in  the  course 
of  diabetes,  and  is  frequently  the  cause  of  death  in  this  disease.  Carbuncle  is 
not  uncommon  during  advanced  life,  and  is  rare  in  childhood.  Debility  from 
acute  and  chronic  diseases  and  from  the  effects  of  bad  food  and  exposure  favor 
its  occurrence.  The  pain  of  carbuncle  is  often  severe,  and  in  the  early  stages 
the  inflamed  skin  is  exquisitely  tender.  When  the  skin  and  subcutaneous  tis- 
sues become  necrotic  the  pain  may  subside.  This  is  especially  true  in  the 
diabetic  and  feeble,  in  whom  the  inflammatory  reaction  of  the  tissues  is  slight. 
I  have  known  instances  of  this  kind  where  the  patient,  his  friends,  and  even 
his  physician  have  been  thus  lulled  into  a  perilously  false  sense  of  security, 
even  when  the  profoundly  septic  patient  was  within  a  day  or  two  of  his 
death. 

The  constitutional  symptoms  of  carbuncle  vary  in  intensity  with  the  extent 
of  the  lesion  and  the  resisting  powers  of  the  patient.  In  the  diabetic  the  symp- 
toms are  those  of  profound  depression  of  all  the  vital  functions.  The  fever 
is  seldom  high,  but  the  pulse  is  rapid  and  feeble  from  the  first.  These  patients 
are  weak  and  prostrated,  and  the  most  powerful  stimulating  measures  produce 
little  or  no  effect.      Operative   removal  of  the  infected  tissues   is   sometimes 


398 


INJURIES    AND    DISEASES    OF    THE    SCALP 


successful,  but  diabetic  coma  or  death  from  septic  absorption  are  the  usual 
endings  of  these  cases.  Carbuncle  affecting  persons  in  otherwise  fairly  good 
condition  rarely  presents  dangerous  symptoms  of  constitutional  poisoning — 
provided  operation  is  undertaken  early.  The  fever  and  prostration  are  moder- 
ate, and  a  rapid  return  to  a 
normal  condition  follows  the 
removal  of  infected  tissues. 
Tuberculous  Ulcers — Lu- 
pus.— Tuberculous  ulcers  of 
the  scalp  may  occur  second- 
ary to  tuberculous  periosti- 
tis or  osteitis  of  the  cranial 
bones — notably  from  middle- 
ear  and  mastoid  disease.  Lu- 
pus of  the  scalp  is  rare  ex- 
cept as  an  extension  from 
the  face.  -    (See  Lupus.) 

Syphilitic  Lesions  of  the 
Scalp. — Chancre  of  the  scalp 
may  occur  from  mediate  con- 
tagion, but  is  exceedingly 
rare.  Secondary  macules, 
papules,  and  pustules  are 
common  on  the  scalp ;  they 
are  commonly  scaly,  with 
the  formation  of  crusts,  and 
often  itch.  Along  the  bor- 
der of  the  hair  upon  the 
forehead  they  constitute  the 
"  Corona  veneris."  Syphil- 
itic alopecia — the  falling  of 
the  hair — may  be  diffuse, 
most  marked  upon  the  crown,  or  in  patches.  It  rarely,  if  ever,  produces 
complete  baldness.  The  gummata  of  tJte  scalp  form  painless  nodules  in  the 
skin — more  rarely  in  the  deeper  soft  parts — varying  in  size  from  a  pea  to 
a  hen's  egg.  At  first  hard,  then  doughy,  later  semifluctuating.  They  grow 
rather  slowly,  and  are  finally  absorbed  or  break  down,  forming  typical  punched- 
out  ulcers,  which  may  slowly  spread  superficially  or  involve  the  skull. 

Ulcerating  Epithelioma. — Ulcerating  epithelioma  occurs  upon  the  scalp,  usu- 
ally as  rodent  ulcer.      (See  Tumors.) 

Emphysema  of  the  Scalp. — Emphysema  of  the  scalp  may  occur  as  the  result 
of  fractures  of  bones  of  the  face  and  skull  which  open  into  air-containing  cav- 
ities— the  frontal  sinus,  the  nasal  fossa,  the  ethmoid  cells,  the  mastoid  cells. 
The  air  usually  accumulates  between  the  galea  and  the  pericranium  in  small 


Fig.  135. — Tuberculous  Abscess  of  the  Scalp  Secondary 
to  Tuberculosis  op  the  Frontal  Bone.  In  this  case  there 
were  numerous  tuberculous  foci  in  other  parts  of  the  body. 
(New  York  Hospital  collection,  service  of  Dr.  Frank  Hart- 
ley.) 


DISEASES    OF    THE    SCALP 


399 


amount  and  over  a  limited  area;  a  swelling  is  produced  of  clastic  quality,  which 
crackles  on  palpation.     Inflammatory  feigns  arc  absent. 

Pneumatocele  capitis. — As  the  result  of  congenital  defects,  or  loss  of  sub- 
stance through  disease  or  injury,  in  the  walls  of  the  air-containing  bony  cav- 
ities of  the  skull  and  face — mastoid  cells,  frontal  sinus,  antrum  of  Highmore — 
accumulations  of  air  may  take  place  between  the  periosteum  and  the  bone,  with 
the  formation  of  rounded  elastic  swellings,  which  diminish  in  size,  or  disap- 
pear on  pressure,  and  grow  larger  from  coughing,  sneezing,  or  other  sudden 
expiratory  effort.  Pneumatocele  arising  from  defects  in  the  mastoid  process 
may  be  congenital  or  acquired,  and  may  spread  upward  and  backward,  and 
in  time  involve  a  large  area  of  the  scalp.  Those  arising  from  the  frontal  sinus 
are  usually  due  to  disease  of  the  bony  wall  of  the  sinus — syphilis  or  tubercu- 
losis— or  to  injury.  They  form  usually  small,  rounded,  elastic  tumors.  The 
diagnosis  of  pneumatocele  capitis  is  made  from  the  presence  of  a  soft  elastic 
tumor,  giving  a  resonant  percussion  note,  painless,  reducible,  and  without  in- 
flammatory symptoms.  Sudden  increase  in  size  occurs  when  the  patient  makes 
an  expiratory  effort  with  the  nose  and  mouth  closed.  The  defect  in  the  wall 
of  the  frontal  sinus  can  sometimes  be  felt  with  the  finger,  in  the  mastoid  proc- 
ess, less  often. 

Aneurisms  of  the  Scalp. — The  temporal  artery  and  its  branches  and  the 
occipital  artery  are  the  favorite  sites  of  cirsoid  aneurism — Angioma  arteriale 
racemosum.     The  tumor  consists  of  a  congeries  of  dilated,  tortuous  arteries 


Fig.  136. — Cirsoid  Aneurism  of  the  Scalp  and  Skull.  In  this  case  the  external  carotid  artery 
had  been  tied  without  any  benefit.  The  tumor  pulsated,  was  soft  and  compressible,  and  beneath 
the  mass  of  dilated  blood-vessels  a  depression  or  loss  of  substance  could  be  felt  in  the  skull.  (The 
patient  was  under  the  care  of  Dr.  L.  W.  Hotchkiss,  through  whose  kindness  the  picture  is  reproduced.) 


400 


INJURIES    AND   DISEASES    OF    THE    SCALP 


and  veins  with  thickened  walls,  forming  a  moderately  elevated  mass  upon  the 
side  of  the  head,  usually  above,  and  in  front  of  the  ear,  and  of  variable  size. 
The  surface  of  the.  tumor  is  covered  with  normal  or  thinned  skin.  The  out- 
line and  blue  color  of  the  individual  vessels  can  be  distinguished.  The  arteries 
leading  to  the  tumor  are  dilated.  The  tumor  is  soft,  pulsates,  diminishes  in 
size  on  pressure,  and  exhibits  a  soft,  intermittent  blowing  murmur.  Pressure 
upon  the  common  carotid  artery  of  that  side  may  or  may  not  cause  the  pulsa- 
tion and  murmur  to  cease,  or  diminish  in  intensity,  and  the  tumor  to  diminish 
in  size. 

Arteriovenous  Aneurism. — Arterio-venous  aneurism  may  occur  in  the  same 
situation  from  traumatism.  It  is  to  be  distinguished  from  the  above  from 
the  following  characters :  The  history  of  injury,  the  presence  of  a  thrill.  The 
murmur  is  continuous.  Pressure  upon  some  point  of  the  tumor  itself  causes 
cessation  of  pulsation,  murmur,  and  thrill.  The  veins  are  especially  dilated; 
the  arteries  leading  to  the  tumor  are  normal.  The  growth  is  more  rapid.  Cer- 
tain angiomata  are  hardly  to  be  distinguished  from  cirsoid  aneurism,  except 
by  absence  of  a  murmur  and  pulsation,  and  the  more  usual  presence  of  pigment 
in  the  skin  over  them,  and  the  involvement  of  the  skin  capillaries,  causing 
"  port-wine  stain."  Sacculated  or  fusiform  aneurisms  of  the  temporal  artery 
are  occasionally  observed  as  the  result  of  trauma.  The  signs  of  aneurism  are 
present. 

TUMORS    OF    THE    SCALP 


Papillomata  of  the  Scalp. — Warts. — Warts,  both  hard  and  soft,  occur  often 
upon  the  scalp.     The  pigmented  hairy  warts  are  sometimes  the  starting  point 

of  melano-sarcoma.  Such  warts 
are  often  tender  and  are  readily 
wounded  and  caused  to  bleed  by 
the  repeated  passage  of  the  comb 
over  them.  Horns  grow  upon  the 
forehead  and  scalp,  sometimes 
from  a  wart,  sometimes  from  a 
sebaceous  cyst.  They  are  yellow- 
ish-brown, brown,  or  almost  black 
in  color,  and  consist  of  stratified 
layers  of  horny  epithelium.  They 
may  be  the  starting  point  of  epi- 
thelioma. Horns  may  reach  a 
length  of  several  inches.  They 
are  attached  to  the  skin,  not  to 
the  bone. 

Sebaceous  Cyst — Atheromatous 

Fig.  137. — Unusually  Large  Sebaceous  Cysts  of  the       Cyst. The   scalp    is   the    favorite 

Scalp.      (New   York    Hospital,   Out-Patient  Depart-  „     ,  „, 

ment,  case  of  Dr.  Hitzrot.)  seat  of  these  tumors.      I  hey  are 


TUMORS    OF    THE    SCALP 


401 


jingle  or  multiple,  and  form  smooth,  rounded,  soft,  or  rather  tense  and  elastic 
sessile  or  pedunculated  tumors,  varying  in  size  from  a  pea  to  a  hen's  egg; 
adherent  at  one  point  to  the  skin.  On  pressure  the  characteristic  sebaceous 
material  can  usually  be  expressed.  They  grow  slowly  and  are  painless,  but 
may  become  infected,  inflamed,  and  ulcerated.  They  are  occasionally  the 
starting  point  of  horns  and  epithelioma. 

Dermoid  Cysts. — Dermoid  cysts  are  of  congenital  origin.     They  are  lined 
with  a  membrane  containing  histological  elements  of  the   skin;    those   upon 


Fig.  138. —  Fibro  -  lipo  -  lymphangioma 
of  the  Scalp,  Neck,  and  Shoulders. 
This  unusual  case  occurred  in  the  serv- 
ice of  Dr.  Charles  McBurney  in  the 
Roosevelt  Hospital.  The  patient  was 
operated  upon  a  number  of  times  and 
considerable  portions  of  the  growth 
were  removed.  The  wounds  always 
bled  furiously  and  the  character  of  the 
tissues  was  such  that  hemostasis  was 
difficult. 


Fig.  139. 


-Result  after  Operations  upon  Case  Shown 
in  Fig.   138. 


the  scalp  contain  oily  or  fatty  material, 
and  sometimes  hair.  Their  favorite  situ- 
ations are  the  outer  angle  of  the  orbit,  the  root  of  the  nose,  the  temporal 
region,  behind  the  ear,  and  in  the  situation  of  the  large  fontanelle.  Der- 
moids bear  a  superficial  resemblance  to  sebaceous  cysts,  but  have  a  deeper 
origin  and  are  adherent  to  the  periosteum  or  bone.  Sometimes  they  sit  in  a 
bony  depression  in  the  skull ;  occasionally  there  may  be  a  hole  in  the  skull 
beneath  them,  and  through  this  they  may  extend  into  the  cranial  cavity ;  such 
dermoids  may  pulsate.  Dermoids  grow  slowly,  and  may  not  be  observed  until 
puberty.  The  diagnosis  is  to  be  made  from  the  situation  of  the  tumor,  its 
deep  attachment  to  the  bone  and  immobility,  its  rounded  shape  and  elastic 
consistence.     A  differential  diagnosis  between  dermoid  and  congenital  hernial 

protrusion  of  the  brain  or  its  membranes  is  usually  possible.      The  hernial 
27 


402 


INJURIES   AND   DISEASES    OF   THE    SCALP 


protrusions  are  situated  over  a  suture ;  they  are  reducible  or  diminish  in  size 
on  pressure  and  during  sleep;  they  pulsate  and  are  increased  in  size  by  sneez- 
ing, coughing,  etc. 

Carcinoma  of  the  Scalp. — Carcinoma  of  the  scalp  occurs  in  two  forms — the 
chronic,  superficial,  ulcerating,  less  malignant  form,  known  as  rodent  ulcer, 
and  the  infiltrating  epithelioma  which  invades  the  deeper  tissues,  and  early 

infects  the  lymph  glands  and  causes 
general  carcinosis.  The  favorite 
situations  are  the  forehead  and  the 
temporal  region.  Chronic  irrita- 
tions and  inflammations  of  the  skin, 
warts,  and  scars,  and,  as  already 
stated,  sebaceous  cysts  in  the  aged, 
are  the  common  starting  points  of 
epitheliomata.      (See  Tumors.) 

Fibroma. — The  hard  fibromata 
rarely  occur  upon  the  scalp.  Soft 
fibroma  (Fibroma  molluscum)  is 
common,  and  may  occur  in  any 
situation,  in  any  number,  and  of 
any  size.  When  large,  they  form 
soft  pendulous  tumors,  which  are 
quite  vascular,  and  often  produce 
extraordinary  deformities.  (See 
Fibroma.) 

Keloid. — Keloid  is  not  infre- 
quent upon  the  scalp  as  the  result 
of  scars,  and  is  very  common  upon 
the  lobule  of  the  ear  in  negro  wom- 
en, as  the  result  of  boring  the  ear 
for  earrings. 

Neurofibromata — Plexiform  Neuroma. — Plexiform  neuroma  has  been  ob- 
served upon  the  forehead,  in  the  temporal  region,  behind  the  ear,  and  in  other 
situations.  They  are  often  pigmented  and  hairy  growths,  sometimes  tender 
and  painful,  of  soft,  rather  uneven  consistence.  They  form  flaccid  tumors 
which  may  give  the  sensation  of  a  bundle  of  worms  beneath  the  skin  upon 
palpation.  They  are  often  combined  with  hypertrophy  of  the  skin  and  sub- 
cutaneous tissues. 

Angiomata.     (See  Cirsoid  Aneurism.) 

Nevus  vasculosus — Angioma  simplex. — Nevus  occurs  upon  the  forehead 
and  scalp  as  a  congenital  tumor,  consisting  of  dilated  capillaries  and  small 
blood-vessels ;  it  is  often  pigmented  and  hairy,  varies  in  size  from  the  frac- 
tion of  an  inch  in  diameter  to  the  size  of  a  hand  or  larger.  Their  peculiar 
pink-red  to  deep-red  or  purple  color  renders  their  diagnosis  simple.     They  are 


Fig.  140. — Angioma  of  the  Scalp,  which  as  the 
Result  of  Injury,  Bled  Profusely.  The  tu- 
mor was  probably  an  angio-sarcoma.  (New  York 
Hospital  collection,  service  of  Dr.  Murray.) 


TUMORS    OF    THE    SCALP 


403 


often  combined  with  lymphangiomata,  and  are  then  pale  in  color.  The  cavern- 
ous angioma,  which  consists  chiefly  of  dilated  vessels  and  spaces  in  which 
the  distinction  between  arteries  and  veins  is  more  or  less  lost,  occur  upon  the 
scalp.  In  structure  they  resemble  the  tissue  of  the  corpus  cavernosum  penis. 
They  form  soft  compressible  tumors,  usually  congenital,  sometimes  pigmented, 
rarely  pulsating. 

Blood  Cysts. — Under  this  title  are  described  cyst  formations,  contain- 
ing venous  blood,  which  occur  upon  the  scalp  and  communicate  with  the 
veins  of  the  interior  of  the  cranium.  Such  blood  cysts  are  situated  be- 
neath the  pericranium,  and 
communicate  by  an  emis- 
sary vein  with  the  longi- 
tudinal sinus.  They  may 
pulsate. 

Lipoma. — Lipoma  is  a 
rare  tumor  upon  the  scalp ; 
when  it  does  occur,  it  is 
most  often  situated  upon 
the  forehead  and  beneath 
the  aponeurosis  of  the  oc- 
cipitofrontal is  or  the  tem- 
poral muscle.  They  form 
rounded  or  flattened  eleva- 
tions, and  upon  palpation 
are  soft  and  elastic.  At  the 
borders  of  the  tumor  there 
is  sometimes  a  thickened 
layer  of  periosteum,  such 
that,  upon  palpation,  the 
tumor  may  feel  as  though 
it  sat  in  a  depression  in 
the  skull.  Very  rarely 
large  lipomata  have  been 
observed  in  the  scalp,  and 
one  case  is  reported  of  a 
negro  woman  who  had  such 
a  tumor  of  enormous   size. 


Fig.  141. 


It    hung    down    as    far 


-Abscess  of  the  Scalp  behind  the  Ear,  Simu- 
lating Mastoiditis. 


as 


her  knees.  In  lipomata  of  the  scalp  the  lobulated  character  of  ordinary 
lipomata  is  usually  wanting;  the  surface  of  the  tumor  is  smooth;  they 
are  but  slightly  movable.  The  differentiation  from  dermoids  depends 
upon  the  localization  of  the  latter,  and  the  fact  that  dermoid  appears 
early  in  life — often  in  infancy — while  lipoma  usually  grows  in  later 
years. 


404         INJURIES  AND  DISEASES  OF  THE  SCALP 

Enchondroma  and  Osteoma. — Enchondroma  and  osteoma  have  very  rarely 
been  observed  in  the  soft  parts  of  the  scalp. 

Endotheliomata. — Endotheliomata  occur  upon  the  head  in  two  forms.  The 
first,  cholesteatoma,  so-called  "  mother-of-pearl "  tumor,  may  appear  in  the 
scalp  as  an  outgrowth  from  the  cranial  bones,  often  from  the  temporal  bone ; 
they  are  sometimes  mistaken  for  sebaceous  cysts  or  dermoids.  Second,  the 
malignant  endothelioma,  or  angiosarcomata,  usually  originate  in  the  cranial 
bones  or  from  the  membranes  of  the  brain.  In  gross  appearance  and  mode  of 
growth  they  are  hardly  to  be  distinguished  from  carcinoma.  They  are  some- 
times very  rich  in  bood- vessels,  and  may  pulsate  and  a  murmur  may  be  present. 

Sarcoma. — The  various  forms  of  sarcoma  originate  in  the  scalp,  in  the 
cranial  bones,  or  in  the  membranes  of  the  brain ;  they  do  not  differ  in  char- 
acter from  sarcomata  elsewhere.     (See  Sarcoma.) 


CHAPTER    XIII 

INJURIES  AND   DISEASES  OF  THE   SKULL 

DIAGNOSIS    OF    INJURIES    OF    THE    SKULL 

In  considering  the  diagnosis  of  injuries  of  the  skull  we  have  to  remember 
that  two  entirely  distinct  sets  of  signs  and  symptoms  may  follow  traumatisms 
of  the  head.  First,  those  due  to  the  injury  of  the  bone  and  the  overlying  soft 
parts,  and  second,  of  far  greater  consequence,  the  signs  and  symptoms  due  to 
injury  of  the  cranial  contents,  the  brain  and  its  membranes,  the  blood-vessels, 
and  the  cranial  nerves.  The  injuries  of  the  bones  of  the  skull  are  relatively 
unimportant,  except  in  so  far  as  they  have  a  bearing  upon  the  immediate  or 
remote  effects  produced  upon  the  cranial  contents.  In  discussing  the  diagnosis 
of  fractures  of  the  skull  I  have  followed  Stimson's  classification,  namely :  cir- 
cumscribed fractures  of  the  vault;  fissured  fractures  with  generalized  brain 
injury;  other  forms. 

Circumscribed  Fractures  of  the  Vault. —  Circumscribed  fractures  of  the  vault 
are  produced  by  direct  violence  acting  over  a  limited  area,  causing  a  fracture 
at  the  point  at  which  the  violence  is  applied.  They  may  or  may  not  be  accom- 
panied by  injury  of  the  cranial  contents ;  such  injury,  if  present,  is  distinctly 
localized.  The  fractures  may  be  of  various  types :  Fissures,  cuts  which  shave 
off  a  portion  of  the  skull ;  fractures  of  the  inner  or  outer  table  alone,  com- 
minuted, with  depression ;  perforations.  Many  of  these  fractures  are  com- 
pound, some  are  simple. 

Fissures. — Fissures  may  be  produced  by  blows,  as  with  a  hammer,  or  by 
cuts  of  a  saber  or  any  sharp-edged  instrument.  The  fissure  may  extend  partly 
or  entirely  through  the  skull ;  may  be  as  long  as  the  portion  of  the  instrument 
which  struck  the  skull,  or  longer.  A  tangential  or  oblique  cut  may  wholly  or 
partly  shave  off  a  fragment,  including  the  outer  table  merely,  or  the  entire 
thickness  of  the  skull.  These  fractures  are  always  compound  and  are  open 
to  direct  inspection;  they  offer  no  difficulties  of  diagnosis  except  that  a  torn 
edge  of  periosteum  may  cause  a  sensation  to  the  examining  finger  which  exactly 
resembles  that  produced  by  the  edge  of  a  fissured  fracture.  The  diagnosis 
should  be  corrected  by  the  eye.  A  suture  in  the  skull  may  resemble  a  fissured 
fracture.  A  fracture  usually  bleeds,  or  may  be  made  to  bleed,  by  scraping  it 
with  a  piece  of  gauze  or  an  instrument. 

Fissured  fractures  of  limited  extent  may  also  be  produced  by  blunt  objects 

405 


406 


INJURIES    AND   DISEASES    OF    THE    SKULL 


which  affect  the  skull  over  a  limited  area ;  such  fissures,  if  simple,  will  give 
rise  to  no  definite  signs  of  fracture  other  than  pain  when  the  line  of  fracture 
is  pressed  upon  with  the  finger.  A  similar  kind  of  violence  may  rarely  pro- 
duce bending  of  the  outer  table  of  the  skull,  and  fracture  of  the  inner  table 
alone.  Such  injuries  are  rare,  and  will  not  usually  be  discovered  unless  they 
are  fatal  from  wound  infection,  or,  as  in  one  reported  case  from  intracranial 
hemorrhage.  Fracture  of  the  external  table  alone  may  result  when  a  bullet 
passes  through  the  skull  from  one  side  to  the  other  and  strikes  the  internal 
table,  bending  it  outward,  and  causes  a  scale  of  bone  to  be  separated  from  the 
external  table  without  perforating.  Such  injuries  are  extremely  rare,  and 
would  not  usually  be  discovered  on  account  of  the  overshadowing  importance 
of  the  injury  of  the  brain. 

Depressed  Fractures  of  the  Skull. — Depressed  fractures  are  usually 
compound  and  comminuted  on  account  of  the  method  of  their  production  by 

blows  from  small,  hard  objects 
— clubs,  stones,  hammers,  and 
the  like.  If  compound,  the  di- 
agnosis is  usually  easy,  the  de- 
pressed fragment,  or  fragments, 
can  be  seen  or  felt  in  the  open 
wound.  If  the  depressed  por- 
tion of  bone  remains  attached  at 
some  part  it  wTill  tend  to  spring 
back  into  place,  and  in  doing  so 
frequently  catches  and  holds 
some  hair.  The  fracture  of  the 
inner  table  is  always  more  ex- 
tensive than  that  of  the  outer. 
In  other  cases  the  fracture  will 
circumscribe  a  more  or  less 
rounded  portion  of  the  skull, 
the  depressed  portion  is  usually 
comminuted,  it  may  be  depressed 
en  masse,  or  the  depression  may 
slope  toward  the  center ;  again 
the  internal  table  will  be  more  extensively  fractured.  From  the  edges  of  the 
depression  one  or  more  fissures  may  be  found,  either  long  or  short,  and  run- 
ning away  from  the  depressed  area. 

If  simple,  the  seat  of  the  depression  can  usually  be  readily  detected  with 
the  finger  through  the  scalp.  A  fallacy,  however,  may  arise,  as  already  spoken 
of  under  contusions  of  the  scalp,  if  the  fracture  is  a  day  or  two  old.  A  hema- 
toma may  be  present  in  the  case  of  a  contusion  without  fracture,  and  a  ring 
of  fibrin  may  be  deposited  around  its  border;  the  examining  finger  feels  this 
ring  of  fibrin,  and  passing  beyond  it  seems  to  sink  into  a  depression  in  the 


Fig.  142. — Simple  Depressed  Fracture  of  the  Skull 
without  Symptoms.  (St.  Mary's  Hospital,  service 
of  Dr.  Charles  N.  Dowd.) 


DIAGNOSIS    OF   INJURIES    OF    THE    SKULL 


40^ 


skull.     The  fibrin  may  be  displaced  by  rubbing  and  pressure,  when  the  appar- 
ent  depression    disappears.      In   case    of    depressed   fractures,    elevation    and 
removal  of  depressed  fragments  may  show  laceration  of  the  dura,  hemorrhage . 
from  the  dura,  from  one  of  the  sinuses,  or  from  an  artery,  or  laceration  of 


Fig.   143. — Depressed  Fracture   of  the  Skull.     (Museum  of  the  New  York  Hospital.) 


the  brain,  or  hemorrhage  from  the  vessels  of  the  pia.  A  portion  of  the  internal 
table  may  be  driven  into  the  brain,  or  a  bullet  or  other  foreign  body  may  be 
discovered.  There  may  be  the  escape  of  brain  tissue,  occasionally  a  flow  of 
cerebro-spinal  fluid. 

Depressed  fractures  of  the  skull  may  be  accompanied  by  the  symptoms  of 
concussion  or  compression  of  the  brain,  and  may  give  rise  to  general  and  local 
symptoms.  The  symptoms  of  concussion  of  the  brain  or  cerebral  shock  are 
immediate.  Partial  or  complete  unconsciousness  following  the  injury,  and 
lasting  for  a  variable  time — from  a  few  moments  to  a  few  hours — the  recovery 
is  rapid  or  gradual.  Vomiting  sometimes  occurs,  and  headache.  Other  symp- 
toms of  shock  may  be  present,  a  rapid  and  feeble  pulse,  paleness,  and  coldness 
of  the  surface,  together  with  shallow,  slow,  or  irregular  breathing.  During 
the  period  of  the  recovery  the  patients  may  be  excited  and  irritable.  Additional 
symptoms  to  these  usually  indicate  contusion  or  laceration  of  the  brain,  or 
cranial  nerves,  or  cerebral  compression  from  intracranial  hemorrhage.  De- 
pressed fractures  of  the  skull  when  they  are  over  some  portion  of  the  motor 
area,  and  are  accompanied  by  paralysis  of  certain  groups  of  muscles,  indicate 
that  the  function  of  the  compressed  portion  of  brain  is  interfered  with,  and  call 
for  operation.  If  the  symptoms  arise  at  once,  the  indication  is  clear;  if  not  for 
several  days,  it  may  be  that  the  symptoms  are  due  to  the  spread  of  an  inflam- 


408  INJURIES   AND   DISEASES    OF    THE    SKULL 

matory  process  having  its  origin  at  a  point  some  distance  away  from  that 
portion  of  the  brain  which  is  giving  rise  to  the  symptoms. 

Complications. — Hemorrhage  from  the  Middle  Meningeal  Artery. — A 
very  important  complication  of  fracture  of  the  vault  of  the  skull,  and  one 
which  may  occur  after  injuries  of  the  head  without  fracture,  is  hemorrhage 
from  the  middle  meningeal  artery  or  one  of  its  branches.  The  middle  me- 
ningeal artery  enters  the  cranium  through  the  foramen  spinosum,  and  runs 
between  the  dura  and  the  skull,  in  a  groove  in  the  latter,  outward,  then  upward. 
The  artery  divides  into  an  anterior  and  posterior  branch.  The  anterior  branch 
passes  upward  and  forward  in  the  direction  of  the  forehead.  The  posterior 
branch  passes  horizontally  backward.  The  anterior  branch  is  more  commonly 
ruptured  in  fracture,  the  posterior  branch  less  often.  In  cases  of  compound 
fracture  of  the  skull  in  which  the  artery  bleeds  externally,  the  situation  of  the 
hemorrhage  may  serve  as  a  guide  to  the  injured  vessel.  In  case  the  point  of 
injury  cannot  be  exactly  localized,  the  anterior  branch  may  be  exposed  by  a 
trephine  opening  or  an  osteoplastic  flap — in  the  adult,  two  fingers'  breadth  above 
the  zygoma  and  one  inch  behind  the  external  angular  process  of  the  frontal  bone. 
The  main  trunk  of  the  artery  as  it  leaves  the  great  wing  of  the  sphenoid  crosses 
the  anterior  inferior  angle  of  the  parietal  bone.  The  posterior  branch  may  be 
exposed  by  an  opening  three  inches  posterior  to  the  first.  In  practice,  the  same 
osteoplastic  flap  may  include  both  branches.     (See  also  Cerebral  Localization.) 

The  symptoms  of  hemorrhage  from  the  artery  may  come  on  at  once,  or  be 
delayed  for  several  hours,  or  even  days.  They  will  vary  somewhat  according 
to  the  rapidity  of  the  bleeding  and  the  amount  and  situation  of  the  hematoma. 
Usually  the  patient  has  few  or  no  symptoms  immediately  after  the  accident. 
The  symptoms  produced  consist  of  localized  paralyses,  and  of  general  symp- 
toms of  compression  of  the  brain.  In  some  cases  the  symptoms  of  concussion 
following  the  injury  will  gradually  merge  into  those  of  compression.  The 
headache,  irritability,  nausea,  and  vomiting  are  followed  by  lethargy,  stupor, 
and  coma.  Paralyses  due  to  compression  of  the  cortical  motor  area  are  local- 
ized to  one  limb  or  set  of  muscles  or  are  more  extensive  (hemiplegia).  In  the 
former  case  the  hemorrhage  is  probably  between  the  dura  and  the  skull ;  in 
the  latter,  beneath  the  dura.  The  paralyses  occur  upon  the  side  of  the  body 
opposite  to  the  injury.  The  pulse  becomes  slow  (the  pulse  of  compression  of 
the  brain).  The  pupils  of  the  eyes  are  of  unequal  size;  the  pupil  is  often 
larger  upon  the  injured  side. 

Gunshot  Fractures  of  the  Skull. — Gunshot  fractures  of  the  skull  have 
been  spoken  of  under  Gunshot  Wounds ;  as  there  pointed  out,  they  vary  in 
gravity  from  mere  contusion  of  bone,  or  the  production  of  a  superficial  furrow 
in  the  outer  table,  to  complete  or  extensive  disorganization  of  the  calvarium. 
Pistol  bullets  of  small  size,  and  fired  at  low  velocity,  may  flatten  against  the 
skull  without  seriously  injuring  the  bone,  or  may  produce  a  perforation  corre- 
sponding in  size  to  the  caliber  of  the  bullet,  without  much  splintering,  and 
enter  the  brain,  producing  serious  or  immediate  fatal  symptoms  from  destruc- 


DIAGNOSIS    OF   INJURIES    OF   THE    SKILL  409 

tion  of  important  centers  in  the  brain  or  medulla;  or,  on  the  other  hand,  they 
may  remain  and  produce  no  symptoms  whatever,  or  he  accompanied  by  imme- 
diate infection  and  abscess  of  the  brain  or  purulent  meningitis;  or  may  produce 
little  or  no  reaction  at  the  time,  and  after  an  indefinite  period  cause  abscess 
or  meningitis,  or  both,  with  fatal  results. 

Extraordinary  contrasts  are  sometimes  presented  by  these  cases.  A  patient 
of  mine  fired  three  shots  from  a  .22  caliber  pistol  upward  into  his  open  mouth, 
lie  was  brought  to  the  hospital  unconscious,  and  with  the  symptoms  of  com- 
pression of  the  brain.  The  unconsciousness  persisted  for  three  days,  and  was 
then  slowly  recovered  from.  There  was  exojmthalmos  of  the  left  eye,  with 
dilatation  of  the  pupil  and  blindness  in  that  eye.  In  the  course  of  two  months 
all  the  signs  and  symptoms  passed  away,  except  that  vision  in  the  left  eye  was 
slightly  impaired.  A  series  of  X-ray  pictures  located  two  of  the  bullets  in 
the  brain  in  the  anterior  fossa  of  the  skull.  Stimson  relates  a  case  in  which  a 
single  No.  7  bird  shot  entered  just  above  the  tendo-oculi,  and  passed  through 
the  lower  part  of  the  frontal  lobe,  directly  back  nearly  to  the  Sylvian  fissure, 
and  caused  death  in  a  week  without  any  evidence  of  inflammation,  and  with 
only  a  minute  intracranial  hemorrhage. 

Fractures  of  the  skull  by  rifle  bullets  of  large  caliber,  and  by  high-powered 
rifles  firing  small-calibered  bullets  at  high  velocities,  produce,  as  already  pointed 
out  under  Gunshot  Wounds,  extensive  destruction  of  the  skull  and  brain.  The 
wound  of  entrance  in  the  scalp  usually  corresponds  with  the  size  of  the  bullet. 
The  wound  of  exit  is  usually  larger,  and  is  accompanied  by  extensive  com- 
minution of  the  skull.  Such  injuries  are  fatal  at  once,  or  within  a  few  hours. 
When  fired  at  distances  less  than  800  meters,  extensive  comminution  and  fis- 
sures surround  the  wound  of  entrance  and  of  exit  in  the  skull.  Beyond  that 
range  the  splintering  and  comminution  of  the  skull  and  the  disorganization  of 
the  brain  diminish,  and  at  extreme  ranges — 2,500-3,000  meters — simple  per- 
forations are  observed  without  explosive  effect.  When  fired  at  long  range, 
however,  small-calibered  rifle  bullets  may  occasionally  lodge  and  remain  in  the 
brain  without  producing  symptoms,  or  the  symptoms,  though  present,  are  dis- 
tinctly localized.  The  fractures  of  the  base  of  the  skull  through  the  mouth, 
the  nose,  or  through  the  orbit,  in  the  form  of  small  perforations,  whether 
produced  by  bullets  or  by  pointed  objects — daggers,  sticks,  umbrella  handles, 
etc. — are  dangerous  and  often  fatal  injuries,  on  account  of  the  unavoidable  and 
frequent  infection  as  well  as  from  injury  of  brain  tissue  and  hemorrhage. 

Fissured  Fractures  with  Generalized  Brain  Injury. — These  are  the  fractures 
produced  by  blunt  violence  such  as  falls  upon  the  head,  crushing  injuries,  falls 
upon  the  buttocks,  feet,  or  knees  from  a  height.  The  mechanism  is  that  the 
skull  is  compressed  in  one  direction  and  forced  to  expand  in  another  beyond 
the  limits  of  its  elasticity,  producing  the  so-called  bursting  and  bending  frac- 
tures, accompanied  by  general  contusion  and  laceration  of  the  brain,  with  hem- 
orrhages from  the  vessels  of  the  dura  and  pia,  or  of  the  brain  substance  itself, 
and  from  the  larger  or  smaller  arteries  passing  through  the  base  of  the  skull 


410  INJURIES    AND    DISEASES    OF    THE    SKULL 

or  the  venous  sinuses ;  injuries  of  the  cranial  nerves  by  hemorrhages  into  their 
sheaths,  less  commonly  by  their  rupture.  For  the  mechanism  of  these  frac- 
tures I  am  compelled,  for  want  of  space,  to  refer  the  reader  to  systematic  works 
on  General  Surgery  and  on  Fractures.  It  may  be  sufficient  here  to  say  that 
these  injuries  commonly  cause  fissured  fractures,  extending  through  the  base 
of  the  skull  in  various  directions.  That  the  fissures  are  frequently  prolonged 
toward  the  vertex,  and  even  circumscribe  the  entire  skull,  so  that  it  is  broken 
into  two  portions,  movable  one  upon  the  other.  The  lines  of  fracture  most 
commonly  cross  the  middle  fossa  of  the  skull,  usually  in  a  more  or  less  trans- 
verse direction,  fracture  the  petrous  portion  of  the  temporal  bone  near  its 
anterior  border,  and  open  into  the  middle  ear.  Sometimes  they  pass  into  the 
anterior  fossa,  and  sometimes  into  the  posterior  fossa. 

There  are,  further,  fractures  of  the  vault  produced  by  great  degrees  of 
violence,  such  that  extensive  simple  or  compound  comminuted  fractures  of  the 
vault  occur,  with  or  without  fissures,  which  may  or  may  not  extend  to  the 
base,  and  accompanied  by  serious  generalized  injuries  of  the  brain.  The  im- 
portance of  both  these  groups  of  fractures,  from  a  diagnostic  point  of  view, 
depends  but  little  upon  the  injury  to  the  skull,  but  upon  the  associated  injuries 
to  the  intracranial  contents. 

Symptoms. — The  symptoms  of  these  fractures  are  those  of  serious  general 
injury  to  the  brain.  There  is  unconsciousness,  more  or  less  complete,  irregu- 
larity of  the  pupils  of  the  eyes,  paralyses  of  greater  or  less  extent,  which  vary 
according  to  the  seat  of  the  injury  to  the  brain  or  to  the  cranial  nerves — to  be 
spoken  of  later.  There  is  a  rise  of  temperature,  usually  moderate  but  which 
may  become  very  high  just  before  death.  The  pulse  is  sometimes  increased 
in  frequency,  and  sometimes  it  is  slower  than  usual.  Respiration  may  be 
affected  in  various  ways,  according  to  the  portion  of  the  brain  injured.  The 
signs  and  symptoms  referable  to  the  fracture  are  hemorrhages  from  the  ears, 
the  nose,  or  the  mouth — the  hemorrhage  may  be  slight  or  profuse — the  escape 
of  cerebro-spinal  fluid  from  the  ear,  from  the  nose,  and  occasionally  through  the 
Eustachian  tube  into  the  throat ;  sometimes  the  escape  of  brain  tissue  through 
the  same  channels.  In  fracture  of  the  base  through  the  middle  fossa  of  the 
skull,  involving  the  petrous  portion  of  the  temporal  bone,  there  is  deafness 
in  the  ear  on  the  injured  side.  It  is  to  be  remembered  that  hemorrhage  from 
the  ear  may  be  caused  by  rupture  of  the  membrana  tympani,  or  fracture  of  the 
anterior  wall  of  the  external  auditory  canal,  caused  by  a  blow  upon  the  chin, 
transmitted  through  the  condyles  of  the  jaw  to  the  temporal  bone.  The  dis- 
charge of  blood  from  the  ear,  from  the  nose,  and  into  the  throat  do  not  con- 
stitute certain  signs  of  fracture  of  the  base. 

The  escape  of  cerebro-spinal  fluid  from  the  ear  may  be  noted  at  once,  or, 
more  commonly,  the  discharge  is  first  bloody,  later  a  mixture  of  blood  and 
cerebro-spinal  fluid.  At  the  end  of  a  day  or  more  the  fluid  may  be  entirely 
clear.  If  the  tympanic  membrane  remains  iutact  and  cerebro-spinal  fluid 
escapes  from  the  ear,  it  indicates  a  fracture  of  the  superior  wall  of  the  external 


DIAGNOSIS    OF   INJURIES    OF   THE    SKULL  411 

auditory  canal.  If  the  tympanic  membrane  is  not  ruptured,  the  fluid  may 
find  its  way  through  the  Eustachian  tube,  and  into  the  throat  or  through  the 
nose.  In  fractures  extending  into  the  anterior  fossa,  also,  cerebro-spinal  fluid 
may  flow  into  the  nose.  The  quantity  of  cerebro-spinal  fluid  discharged  varies. 
It  is  usually  greatest  from  the  ear.  It  may  amount  to  several  ounces,  or  to 
as  much  as  a  piut,  in  twenty-four  hours.  The  fluid  is  alkaline  in  reaction, 
contains  a  considerable  quantity  of  sodium  chlorid,  and  very  little  albumen. 
A  copious  discharge  of  lymph  may  take  place  from  the  ear,  containing  a  large 
quantity  of  albumen.  Such  lymph  may  be  derived  from  the  lymph  space  of 
Schwalbe  in  the  labyrinth.  Two  other  varieties  of  discharge  may  be  noted. 
"  The  flow  is  abundant  and  albuminous,  becoming  scanty  and  purulent ;  prob- 
ably an  inflammatory  discharge  from  the  surface  of  the  cavity  of  the  tympanum. 
Or  the  flow  is  scanty,  appears  later,  is  albuminous  and  reddish,  and  is  probably 
the  serum  of  extravasated  blood."     (Stimson,  "  Fractures  and  Dislocations.") 

The  escape  of  brain  substance  from  the  ear  or  from  the  nose  is,  of  course, 
a  certain  sign  of  fracture  of  the  base,  with  laceration  of  the  membranes  of  the 
brain,  and  of  the  brain  itself.  There  are  frequently  ecchymoses.  The  most 
common  situation  is  beneath  the  conjunctiva,  spreading  to  the  eyelids.  It  is 
especially  marked  in  fractures  of  the  orbital  plate  of  the  frontal  bone.  Similar 
ecchymosis  may  be  observed  in  the  skin  behind  the  ear ;  it  usually  appears  a 
few  days  after  the  injury ;  also  in  the  mucous  membrane  of  the  throat.  When 
an  extensive  hemorrhage  takes  place  into  the  orbit  there  may  be  exophthalmos. 

Fractures  through  the  mastoid  cells,  or  the  frontal  sinus,  or  the  ethmoid 
cells,  may  be  accompanied  by  moderate  subcutaneous  emphysema.  The  par- 
alytic symptoms  depend  partly  upon  contusion  and  laceration  of  the  brain,  or 
upon  intracranial  hemorrhage,  or  upon  laceration  of  or  pressure  upon  the  cra- 
nial nerves.  Paralysis  of  the  extremities  is  more  commonly  due  to  intracranial 
hemorrhage  and  pressure  upon  the  motor  area  than  upon  laceration  of  the 
brain.  A  slow  pulse  usually  indicates  pressure  upon  or  hemorrhage  into  the 
medulla,  and  the  same  is  usually  true  of  disturbances  of  respiration.  Injury 
of  or  pressure  upon  centers  in  the  brain  itself  is  attended  by  paralysis  upon  the 
opposite  side  of  the  body.  Injuries  of  the  cranial  nerves  by  paralysis  upon 
the  same  side  of  the  body.  They  may  be  due  to  rupture  of  the  trunk  of  the 
nerve — usually  when  the  line  of  fracture  crosses  its  foramen — or  to  pressure, 
or  to  hemorrhage  into  the  sheath  of  the  nerve.  The  facial  nerve  is  more  often 
injured  than  others.     Next  in  frequency  the  abducens. 

The  most  striking  symptom  of  fracture  of  the  base  of  the  skull  is  more  or 
less  complete  coma.  This  must  be  differentiated  from  alcoholic  and  uremic 
coma,  and  from  apoplexy  and  opium  poisoning.  The  history  of  an  injury  to  the 
head  is  important.  Alcoholic  coma  is  rarely  as  profound  as  that  due  to  injury 
of  the  brain.  The  odor  of  alcohol  upon  the  breath  is  a  sign  which  has  landed 
many  an  individual  with  fracture  of  the  base  of  the  skull  or  apoplexy  in  the 
police  station.  The  pupils  are  equal  in  the  coma  from  alcohol.  If  the  patient 
be  sharply  slapped  upon  the  face,  the  pupils  of  the  eyes  will  usually  rapidly 


412  INJURIES   AND   DISEASES    OF    THE    SKULL 

dilate  and  then  contract  again.  There  is  no  paralysis.  The  coma  of  apoplexy 
is  complete.  The  breathing  is  stertorous,  the  pulse  is  usually  slow.  There  is 
hemiplegia  or  paraplegia.  In  opium  poisoning  the  pupils  are  contracted  to 
pin-point  size,  and  remain  so.  The  patient  can  sometimes  be  momentarily 
roused;  there  is  no  paralysis.  In  uremic  coma  there  will  be  evidences  of 
nephritis,  sometimes  edema  of  the  extremities;  urine  withdrawn  through  a 
catheter  will  be  albuminous,  and  contain  casts;  there  are  sometimes  general 
convulsions;  there  is  no  paralysis.  An  examination  of  the  fundus  of  the  eye 
with  an  ophthalmoscope  may  show  evidences  of  degeneration  of  the  retina,  and 
other  signs  common  in  nephritis. 

DISEASES    OF   THE    SKULL 

Acute  Inflammation  of  the  Periosteum  of  the  Skull  (Pericranitis  acuta). — 
Acute  purulent  inflammation  of  the  pericranium  occurs  as  the  result  of  in- 
fected wounds  of  the  overlying  soft  parts,  or  as  an  extension  of  inflammatory 
processes  of  the  soft  parts  or  of  the  bone,  as  abscess  of  the  scalp,  erysipelas, 
disease  of  the  middle  ear  or  mastoid  process,  and  as  a  complication  of  infected 
fractures  or  of  acute  osteomyelitis  of  the  cranial  bones.  In  the  most  acute 
cases  the  disease  may  be  ushered  in  by  a  chill,  a  rapid  elevation  of  temperature, 
and  all  the  symptoms  of  acute  sepsis.  Locally  the  patient  will  complain  of 
headache;  the  scalp  will  be  swollen  and  edematous  and  doughy,  but  may  be 
normal  in  color  if  the  inflammation  is  primary  in  the  periosteum.  The  swollen 
area  will  be  tender  on  pressure,  and  beneath  the  scalp  there  will  be,  at  first,  an 
indurated  swelling  connected  with  the  bone,  over  which  the  scalp  may  be  mov- 
able. Later  there  will  be  deep  fluctuation ;  the  swelling  and  edema  may  extend 
into  the  neck  or  the  face.  Frequently  the  disease  is  secondary  to  phlegmonous 
inflammations .  of  the  scalp.     The  constitutional  symptoms  are  often  grave. 

Acute  Inflammation  of  the  Cranial  Bones — Acute  Osteomyelitis. — Acute  osteo- 
myelitis occurs  as  the  result  of  infected  wounds  of  the  soft  parts,  of  infected 
fractures  of  the  skull,  and  of  phlegmonous  and  other  inflammations  of  the 
scalp.  The  disease  is  usually  associated  with  inflammation  of  the  pericranium 
and  of  the  dura.  Only  in  isolated  cases  has  it  been  observed  confined  to  the 
spongy  tissue  of  the  diploe.  The  bone  appears  of  a  yellow  color  instead  of  its 
normal  pinkish-Avhite.  The  condition  is  scarcely  to  be  regarded  as  a  diagnostic 
entity,  and  is  usually  a  portion  of  the  pathological  process  in  acute  purulent 
infection  of  the  dura  and  pia,  and  of  sinus  thrombosis  and  pyemia  following 
infected  fractures  and  wounds  of  the  skull,  and  sometimes  accompanying  mas- 
toid disease.  The  signs  and  symptoms,  therefore,  are  rather  those  of  inflam- 
mation of  the  membranes  of  the  brain,  etc.,  than  of  the  inflammation  of  the 
bone  itself,  and  will  be  discussed  under  these  topics.  The  chronic  inflamma- 
tions of  the  bones  of  the  skull  are  chiefly  tubercular  and  syphilitic. 

Tubercular  Inflammation  of  the  Skull. — Tubercular  inflammation  of  the  skull 
may  be  primary  or  secondary  to  tubercular  disease  of  the  soft  parts  of  the  face 


DISEASES    OF   THE    SKULL  413 

(lupus)  or  of  the  scalp,  or  most  frequently  of  the  middle  ear.  Primary  tuber- 
cular disease  of  the  skull  occurs  most  frequently  on  the  forehead  and  the  pari- 
etal region.  In  young  persons,  usually  only  in  those  who  have  other  tubercular 
foci.  The  signs  and  symptoms  are  a  slowly  developed,  tender,  painful,  cir- 
cumscribed, doughy  swelling,  which  later  fluctuates;  incision  evacuates  tuber- 
culous pus  and  reveals  a  more  or  less  extensive  area  of  tubercular  caries  of  the 
underlying  bone ;  sometimes  absorption  of  bone  and  loss  of  substance,  extend- 
ing through  the  thickness  of  the  skull.  The  lesion  has  the  characteristic  appear- 
ances of  tuberculosis.  Tubercular  meningitis  or  general  tuberculosis  are  not 
uncommon  complications.  The  secondary  tubercular  inflammations  of  the  skull 
occur  most  often  as  the  result  of  tuberculous  inflammation  of  the  middle  ear 
and  of  tuberculous  ulcerations  of  the  nasal  mucous  membrane.  The  diagnosis 
must  be  made  from  the  situation,  the  character  of  the  discharge,  the  recognition 
of  tubercle  bacilli,  the  chronic  course,  and  the  presence  of  tuberculosis  else- 
where. 

Syphilis  of  the  Cranial  Bones. — Syphilis  of  the  cranial  bones  occurs  in  the 
form  of  circumscribed  or  diffuse  periostitis,  or  of  gummata.  Syphilitic  peri- 
ostitis is  common  in  the  form  of  the  so-called  syphilitic  nodes  on  the  frontal 
and  parietal  bone.  They  occur  in  the  later  stages  of  the  disease,  and  form  firm 
or  elastic,  rounded,  moderately  elevated,  tender  swellings,  single  or  multiple, 
of  varying  size  from  a  fraction  of  an  inch  to  an  inch  or  more  in  diameter. 
They  run  a  chronic  course,  lasting  for  months,  sometimes  for  years.  They  may 
disappear  under  treatment,  leaving  the  bone  intact  or  pitted,  or  break  down  and 
ulcerate,  leaving  characteristic  punched-out  ulcers.  They  may  cause  syphilitic 
caries  or  necrosis,  with  loss  of  substance,  and  leave  extensive  defects  in  the 
skull.  The  condition  is  exceedingly  chronic,  and  the  process  may  extend  over 
years. 

Gummatous  periostitis  may  also  be  diffuse,  and  cover  in  time  the  greater 
part  of  the  vault  of  the  skull.  The  process  tends  to  advance  slowly.  The 
lesions  are  often  multiple  gummy  nodules,  which  coalesce.  Breaking  down  and 
ulceration  are  common.  Destruction  of  bone  may  be  superficial,  leaving  behind 
a  peculiar  and  characteristic  worm-eaten  appearance  of  the  surface  of  the  skull, 
or  deep-seated,  causing  caries  or  necrosis  of  the  entire  thickness  of  the  skull, 
with  extensive  perforations  and  loss  of  substance.  Characteristic  of  the  process, 
also,  is  the  production  of  new  bone,  nodular  or  diffuse  thickenings  of  the  skull, 
syphilitic  hyperostoses.  The  destructive  and  productive  processes  may  proceed 
side  by  side.  When  the  soft  parts  soften  and  break  down,  extensive  ulcers  form. 
The  necrotic  bone  surfaces  are  exposed.  Putrefactive  changes  take  place.  The 
bone  turns  green  or  black ;  the  discharge  of  pus  is  often  profuse,  and  has  a 
stinking  and  horribly  offensive  odor.  Gummata  also  occur  in  the  spongy  tissue 
of  the  diploe,  and  upon  the  surface  of  the  inner  table  of  the  skull.  They  also 
may  lead  to  caries,  necrosis,  and  the  production  of  new  bone,  and  are  frequently 
complicated  by  inflammations  of  the  dura  (pachymeningitis  syphilitica  gum- 
mosa) ;  severe  continuous  headache  is  a  characteristic  symptom. 


414 


INJURIES    AND   DISEASES    OF    THE    SKULL 


Necrosis  of  the  Skull. —  Necrosis  of  the  skull  follows  infected  fractures  or 
wounds  and  osteomyelitis  of  the  cranial  bones  and  necrotic  inflammations  of 
the  overlying  soft  parts,  with  extensive  destruction  of  the  pericranium.  It  is 
rare  as  the  result  of  aseptic  operations.  The  necrosis  may  be  superficial,  or 
involve  the  entire  thickness  of  the  skull.  No  involucrum  is  formed.  The  dead 
bone  separates  slowly,  and  loss  of  substance  is  replaced  usually  by  fibrous  scar 
tissue  merely,  rarely  by  bone. 

Imperfect  Ossification  and  Atrophy  of  the  Skull — Imperfect  ossification  of 
the  skull  may  occur  as  a  congenital  condition  thought  to  be  due  to  congenital 
rachitis  or  syphilis.  The  vault  of  the  skull  may  consist  of  numerous  small 
bony  plates,  with  soft  places  between  and  abnormally  large  fontanelles.  Local- 
ized atrophy  may  occur  from  the  pressure  of  tumors — notably  dermoids — or 
from  aneurisms.  Atrophy  occurring  after  birth  in  children  is  usually  due  to 
rachitis  (craniotabes  rachitica).  The  softening  of  the  bone  is  most  marked 
in  the  occipital  region,  and  may  reach  a  grade  such  that  the  skull  can  be 
impressed  with  the  fingers.  The  symptoms  of  cerebral  compression  or  convul- 
sions may  occur  in  such  cases.  A  similar  condition  has  been  observed  in  adult 
women  suffering  from  osteomalacia. 


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Fig.  144. — Diffuse  Hypf.rtrophy  of  the  Skull.     (New  York  Hospital  Museum.) 


Hypertrophy. — Diffuse  and  circumscribed  hypertrophies  of  the  skull  may 
occur  both  on  its  outer  and  inner  surface.  In  the  diffuse  form  all  the  bones  of 
the  skull  and  face  may  become  greatly  tbickened    (leontiasis  ossium).     The 


DISEASES    OF    THE    SKULL  415 

circumscribed  hypertrophies  in  the  interior  of  the  skull  may  gradually  cause 
cerebral  compression  and  death  from  atrophy  of  the  brain. 

Aneurism  of  the  Arteries  of  the  Skull. — Aneurism  of  the  arteries  of  the  skull 
may  be  single  or  multiple ;  they  produce  at  first  bony  swellings  upon  the  skull ; 
later  the  bone  is  thinned,  and  crackles  on  compression ;  finally,  the  bony  cover- 
ing is  absorbed,  and  a  soft,  pulsating  tumor  appears,  giving  the  signs  of  aneu- 
rism. Rupture,  externally  or  into  the  cranial  cavity,  causes  death  from  hem- 
orrhage or  cerebral  compression.  A  few  cases  of  aneurism  of  the  middle 
meningeal  artery  have  been  reported. 

Tumors  of  the  Cranial  Bones. — Enchondromata  may  originate  in  the  ethmoid 
bone  and  grow  into  the  frontal  sinus,  the  nasal  fossa?,  or  the  orbit ;  they  usually 
become  converted  into  bony  tumors,  and  cause  symptoms  mechanically — dis- 
placement of  the  eyeball,  stoppage  of  the  nasal  fossa?,  etc.  They  are  to  be 
recognized  by  their  stony  hardness.  Bony  tumors  may  grow  from  the  outer 
or  inner  surface  of  the  skull  or  from  the  diploe.  They  are  usually  sessile 
tumors,  are  of  slow  growth,  and  smooth  or  uneven  surface  and  hard  consistence. 
On  the  outer  surface  of  the  skull  the  history  and  physical  characters  of  the 
tumor,  or  an  X-ray  picture,  establish  the  diagnosis.  In  the  interior  of  the 
skull  they  may  reach  a  considerable  size  and  yet  produce  no  cerebral  symptoms ; 
occasionally  they  may  impair,  by  pressure  or  stretching,  the  functions  of  one 
or  more  of  the  cranial  nerves.  A  mistake  in  diagnosis  is  possible  between  an 
osteoma  and  a  central  sarcoma  of  bone  before  it  has  caused  complete  absorption 
of  its  bony  covering.  An  X-ray  picture  will  show  whether  the  tumor  consists 
of  bone  or  soft  tissues.  I  saw  a  case  of  osteoma  of  both  orbits  and  double 
exophthalmos  when  I  was  interne  in  Bellevue  Hospital ;  there  were  no  sub- 
jective symptoms. 

Sarcoma. — Any  of  the  forms  of  sarcoma  may  occur  in  the  skull.  They 
originate  in  the  periosteum,  from  the  bone  itself  or  from  the  dura.  Here,  as 
elsewhere,  they  are  apt  to  be  rapidly  growing  tumors,  and  in  the  skull  destroy 
life,  after  a  variable  period,  from  hemorrhages,  from  interference  with  the 
functions  of  the  brain,  meningitis,  sepsis.  They  all  tend  to  penetrate  the 
skull  inwardly  or  outwardly,  according  to  their  original  site.  Those  which 
grow  from  the  pericranium  form  tumors  of  softer  or  harder  consistence,  accord- 
ing to  their  type ;  they  may  reach  a  large  size  before  producing  much  general 
or  local  disturbance.  Ulceration,  sloughing,  and  dangerous  bleeding  are  apt 
to  occur  sooner  or  later,  and  the  skull  is  sometimes  penetrated  and  the  dura 
and  brain  involved  quite  early  in  the  disease  in  spite  of  the  absence  of  symp- 
toms. Those  which  originate  in  the  bone  remain  covered  by  a  thin  bony  en- 
velope for  some  time,  and  may  set  up  such  an  irritation  that  considerable  new 
bone  is  produced  in  the  form  of  osteophytes.  The  bony  covering  is  finally 
perforated,  and  a  loss  of  substance  can  be  felt,  through  which  the  tumor  con- 
tinues to  grow. 

The  sarcomata  arising  from  the  dura  may  simply  infiltrate  the  skull,  and 
thus  infect  the  overlying  soft  parts,  or  they  cause  absorption  and  perforation 


416 


INJURIES   AND   DISEASES    OF   THE    SKULL 


of  the  skull ;  after  such  perforation  they  may  receive  transmitted  pulsation 
from  the  brain ;  later,  as  the  tumor  grows  and  spreads  in  the  tissues  of  the 
scalp,  the  pulsation  is  no  longer  felt.  Secondary  tumors  in  the  head  and  else- 
where may  occur  if  the  patient  survives  for  a  sufficient  time.  The  sarcomata 
of  the  dura  afford  the  worst  possible  prognosis,  those  from  the  bone  almost  as 

bad;  those  from  the  pericranium  may  occa- 
sionally be  cured  by  operation.  It  is  not 
always  easy,  nor  even  possible,  to  determine 
whether  a  sarcoma  has  originated  in  the 
bone  or  from  the  interior  of  the  skull.  Soon 
after  a  sarcoma  of  the  dura  has  perforated 
the  skull  it  may  pulsate  and  be  partly  re- 
ducible, which  points  to  an  intracranial  ori- 
gin. As  the  tumor  grows  these  signs  are 
apt  to  be  obscured.  The  differential  diag- 
nosis between  aneurism  and  pulsating  sar- 
coma has  already  been  referred  to  under  the 
head  of  Aneurism.  It  should  be  remem- 
bered that  absence  of  cerebral  symptoms 
Jt  does  not  necessarily  indicate  that  the  tumor 

has  not  invaded  the  interior  of  the  skull. 
In  the  perforations  from  without,  the  dura 
may  long  remain  intact  and  the  brain  be 
gradually  pushed  away  by  the  growth  of 
the  tumor  without  producing  cerebral  symptoms.  The  favorite  sites  for  sar- 
coma of  the  skull  are  the  parietal  and  frontal  regions.  They  may  also  develop 
from  the  base  of  the  skull  and  elsewhere.  I  operated  in  1896  upon  a  sarcoma 
of  the  skull  in  the  frontal  region;  the  tumor  grew  in  the  diploe,  and  had  not 
perforated  the  internal  table.  It  was  as  large  as  a  man's  fist.  The  patient- 
remained  well  for  three  years,  when  I  lost  sight  of  him. 


Fig.  145. — Ulcerated  Sarcoma  of  the 
Skull.  (Collection  of  Dr.  Charles  Mc- 
Burney,  Roosevelt  Hospital.) 


CHAPTER    XIV 

THE   INJURIES  AND   DISEASES  OF  THE   BRAIN  AND   ITS  MEMBRANES 

GENERAL    CONSIDERATIONS 

Injuries  and  diseases  of  the  brain  give  rise  to  symptoms  and  signs,  local 
and  general,  some  of  which  depend  upon  interference  with  the  function  of 
the  brain,  as  a  whole,  and  some  upon  disturbances  of  certain  limited  portions 
of  brain  tissue.  If  these  disturbances  occur  in  parts  of  the  brain  whose  func- 
tion is  known,  definite  symptoms  are  produced,  such  that  in  some  instances 
we  are  able  to  apply  appropriate  surgical  treatment  for  relief.  In  many  cases 
of  injury  the  history  of  the  accident,  the  presence  of  a  wound,  a  fracture,  of 
external  bleeding,  etc.,  may  be  sufficient  guides  to  the  seat  of  the  trouble;  in 
others  we  are  obliged  to  depend  upon  the  aforesaid  disturbances  of  brain 
function. 

Injuries  of  the  brain  are,  however,  often  of  a  complicated  character;  the 
symptoms  of  cerebral  shock  or  concussion  may  mask  those  of  compression,  con- 
tusion, or  laceration.  The  lesions  are  often  multiple.  Many  of  them  are  soon 
complicated  by  infection  and  suppurative  inflammation  of  the  brain  and  its 
membranes  of  a  progressive  character,  producing  new  local  and  general  symp- 
toms such  that  the  symptoms  of  the  original  lesion  are  entirely  overshadowed. 
Certain  large  areas  of  the  brain  may  be  injured  or  destroyed  and  yet  no  symp- 
toms, or  only  indefinite  symptoms,  will  follow ;  so  that  our  ability  to  localize 
foci  of  injury  or  disease  in  definite  portions  of  the  brain  is  limited  in  many 
directions.  The  functions  of  certain  portions  of  the  brain  are,  however,  defi- 
nitely known  as  well  as  their  relations  to  the  surface  of  the  cranium,  and  these 
data  are  at  times  valuable  in  the  diagnosis  and  treatment  of  lesions  of  the  brain, 
traumatic  or  pathological. 

Cerebral  Localization  * 

At  the  present  time  it  is  the  generally  accepted  view  that  the  Rolandic,  or 
central,  fissure  divides  the  cortex  of  the  brain  into  an  anterior  motor  field  and 
a  posterior  sensory  field.  This  division  of  the  brain  was  worked  out  by 
Professor  Sherrington  in  the  anthropoid  apes,  and  has  been  shown  to  be  true 
also  for  man  by  Krause,  Frazier,  and  Cushing. 

1  Partly  adapted  from  Harvey  Cushing,  "  Keen's  Surgery,"  vol.  iii,  p.  155  et  seq.,  W.  B. 
Saunders,  1908. 

28  417 


418 


INJURIES    AND   DISEASES    OF   THE   BRAIN 


The  Motor  Area  of  the  Cortex. — Contrary  to  the  former  belief,  which  placed 
the  motor  area  of  the  cortex  both  before  and  behind  the  central  fissure,  more 
recent  investigations  have  shown  that  upon  the  exposed  surface  of  the  convexity 
of  the  brain  the  motor  area  is  limited  to  a  narrow  strip  about  one  centimeter 


Fig.  146. — Brain  of  Gorilla,  Showing  Excito-motor  Area  as  Delineated  by  Cortical  Fara- 
dization. Note  the  presence  of  the  three  genua  {superior,  opposite  body;  middle,  opposite  neck 
areas).      (Kindness  of  Prof.  Sherrington.) 

in  width,  situated  in  the  anterior  central  gyrus,  extending,  however,  to  the 
depth  of  the  central  fissure.  Thus  a  lesion  involving  the  motor  cortex  may 
be  removed  some  distance  from  the  superficial  portion  of  the  brain.  The  upper 
limit  overlaps  on  the  mesial  surface  of  the  hemisphere  (the  paracentral  lobule). 
The  lower  limit  does  not  extend  as  far  as  the  fissure  of  Sylvius. 

The  Rolandic  fissure  is  not  a  straight  line,  but  is  broken  by  two,  or  sometimes 
three,  more  or  less  well-developed  angles  (genua),  formed,  I  believe,  by  the  swell- 
ings above  and  below  them,  made  by  the  aggregations  of  cells  controlling  move- 
ments in  the  leg,  arm,  face,  and,  still  lower  clown,  jaws,  tongue,  etc.  Opposite  to 
the  upper  two  genua  the  motor  strip  is  less  wide  and  its  representative  movements 
less  complex,  occurring  as  they  do  in  the  neek  and  trunk.  Thus  the  genua  are 
valuable  surgical  landmarks,  particularly  the  middle  and  inferior  ones,  for  they  are 
more  often  brought  into  view.  Above  the  superior  genu  there  is  but  a  small  tri- 
angle of  motor  cortex  which  can  be  exposed,  and  it  gives,  on  stimulation,  move- 
ments in  hip,  knee,  and  toe:  opposite  to  this  genu  lie  centers  for  movements  of 
thorax  and  abdomen;  between  it  and  the  middle  genu  lie  centers  for  the  upper 
extremity,  the  shoulder  being  represented  higher  than  fingers  and  thumb;  oppo- 
site to  the  middle  genu  are  centers  for  the  neck,  and  below  it  those  for  the  face, 
eyelids  above  and  lips  below;  center  for  jaws,  tongue,  vocal  cord,  pharynx,  etc.,  are 
the  still  lower,  usually  below  an  inferior  genu   (Cushing). 


GENERAL   CONSIDERATIONS 


419 


Destruction  or  removal  of  these  areas  produces  motor  paralysis  of  the  cor- 
responding muscles.     Sensation  is  not  affected. 


T.   OF  ROLANDO 


Certain  complex  movements  of 
a  higher  order  may  be  obtained  by 
stimulation  of  areas  adjoining  the 
true  motor  cortex.  Thus,  below 
the  anterior  central  gyrus  is  the 
pars  opercularis ;  sucking,  chewing, 
sneezing,  and  vocalizing  movements 
may  be  obtained  (note  that  this  is 
near  the  vocal  speech  center  of  Bro- 
ca),  and  from  the  gyrus  frontalis 
medius  movements  of  the  head  and 
eyes  to  the  opposite  side  may  be 
elicited.  The  pathway  from  the 
motor  cortex  is  the  pyramidal  tract, 
whose  fibers  degenerate  throughout 
their  full  length  after  injury  to 
their  cortical  cells   (Gushing). 


The   Sensory 

sory   area   for   common 


PAROCCIP. 
-TISSURt 

AMBOA 


Field. — The  sen- 
sensation 
lies  in  the  posterior  central  gyrus. 
The  area  occupies  a  position  in 
the  posterior  central  convolution 
similar  to  that  of  the  motor  area 
in  the  anterior  central  convolution. 
It  lies  largely  in  the  cortex  buried 
in  the  fissure,  and  occupies  super- 
ficially only  about  half  of  the 
postcentral  gyrus. 


The  fibers  to  the  sensory  field 
pass  from  the  thalamus  in  the 
"cortical  lemniscus"  (Monakow) 
of  the  corona  radiata  to  the  post- 
Rolandic  territory.  In  their  course 
they  lie  in  the  posterior  part  of  the 
capsula  interna.  The  forms  of  sen- 
sation, registration  of  which  we  may 
now  with  some  assurance  place  in 
the  near  post-central  region,  are  the 
tactile  sense,  the  muscular  sense, 
and  the  power  of  discriminating 
points   in   contact.      It   is   evident   also 


Fig.  147a.  —  Diagram  Showing  the  Relations  op 
the  more  Important  Fissures  and  Convolu- 
tions to  the  Sutures  and  Bony  Landmarks  of 
the  Skull.      (From  Woolsey.) 


BREGMA 


MID.  POINT 


GLABELLA* 


Fig.  1476  — Diagram  Showing  the  Relations  of 
the  Fissures  of  Rolando  and  Sylvius,  the 
Middle  Meningeal  Artery  and  the  Lateral 
Sinus,  to  the  Bony  Landmarks  and  Sutures 
of  the   Skull.     (From  Woolsey.) 


that   as   one   ffoes   farther   back   from   the 


fissnra  centralis  and  approaches  the  posterior  association  field  of  Flechsig,  sensation 


420  INJURIES    AND   DISEASES    OF   THE   BRAIN 

becomes  more  complex,  so  that  more  extensive  and  deeper  lesions  are  necessary  to 
interrupt  its  transmission.  The  senses  of  pain  and  of  temperature  lie  probably  in 
the  intermediate  post-central  zone  of  Campbell,  and  that  for  the  recognition  of 
objects — the  stereognostic  sense  in  particular — is  located  as  far  back  as  in  the 
parietal  lobe  (Walton  and  Paul). 

The  Visual  Cortex. — The  primary  perceptions  of  sight  are  registered  in  the 
occipital  lobe,  especially  on  its  mesial  surface  in  the  calcarine  region. 

The  visuopsychic  field  extends  on  the  outer  surface  (of  the  left  side)  in  the 
second  occipital  convolution  as  far  as  the  angular  gyrus,  where  lies  the  visual 
word  center  (reading)  which  participates  in  the  speech  mechanism.  The  lingual 
lobule  below  the  calcarine  fissure  appears  to  be  associated  with  color  perception. 

The  Auditory  Cortex. — The  superior  temporal  gyrus  receives  the  sensations 
of  sound  which  are  converted  into  conscious  perceptions  in  the  adjoining  por- 
tions of  the  temporal  lobe,  "  those  on  the  left  side,  in  particular,  being  con- 
cerned with  the  auditory  end  of  the  speech  mechanism.  Extensive  lesions  on 
the  right  side  may  give  rise  to  no  appreciable  impairment  of  hearing  on  the 
same  side,  and  there  is  much  confusion  over  the  unilaterality  or  otherwise  of 
the  registration  of  auditory  impulses." 

The  Sense  of  Smell. — The  pyriform  lobe  is  generally  regarded  as  the  chief 
cortical  center  for  the  sense  of  smell. 

The  sense  of  taste  lies  probably  at  the  lip  of  the  limbic  lobe,  in  the  neigh- 
borhood of  the  uncus. 

This,  topographically  speaking,  would  place  both  of  these  areas,  for  taste  and 
smell,  in  a  situation  just  to  the  outer  side  of  the  pituitary  fossa — a  matter  of  con- 
siderable importance,  as  lesions  confined  to  this  area  of  the  limbic  lobe  not  only 
give  characteristic  symptoms,  but  are  surgically  approachable   (Cushing). 

The  Speech  Areas. — The  speech  areas  are  in  the  left  hemisphere  in  right- 
handed  persons.  They  are  four  in  number:  (1)  The  area  for  the  recognition 
of  spoken  words  lies  in  the  superior  temporal  gyrus.  (2)  The  center  for  motor 
speech  lies  in  the  inferior  frontal  convolution.  (3)  The  visual  word  center 
is  in  the  angular  gyrus.  (4)  The  power  of  writing  is  lost  when  the  median 
frontal  gyrus  is  destroyed. 

The  General  Cortex  and  Frontal  Lobes There  are  large  areas  of  the  cortex 

whose  function  is  unknown.  They  are  more  extensive  on  the  right  hemisphere 
than  on  the  left.  Many  of  these  areas  are  doubtless  concerned  with  the  more 
complex  mental  processes  (association).  The  frontal  lobes  of  the  brain  appar- 
ently have  to  do  with  the  higher  mental  faculties — i.e.,  attention,  reasoning, 
and  self-control — and  lesions  of  the  frontal  lobes,  notably  upon  the  left  side, 
are  commonly  attended  by  dullness,  apathy,  loss  of  the  power  of  concentration, 
and  imperfect  self-control. 


Diagrams  Illustrating  the  More  Definitely  Localized  of  the  Cortical  Centers  of  the 
Exposed  Parts  of  the  Hemisphere,  in  Relation  to  the  Main  Fissures  and  Convolu- 
tions; also  the  "Word  Centers"  (Sensory  and  Motor)  Involved  in  the  Special  Mech- 
anism for  Speech.  (Recetving  Sensory  Stations  in  Blue;  Discharging  Motor  Stations 
in  Red.)     Keen's  Surgery.) 


GENERAL   CONSIDERATIONS  421 

The  Basal  Ganglia. — The  corpora  striata  and  the  optic  thalatni  are  not  ac- 
cessible to  surgical  treatment.  The  same  may  be  said  of  the  crura  cerebri,  cor- 
pora quadrigemina,  and  pons.  Lesions  of  the  caudate  and  lenticular  nuclei 
and  internal  capsule  produce  paralysis  upon  the  opposite  side  of  the  body  and, 
if  the  posterior  part  of  the  capsule  is  involved,  sensory  disturbances.  Lesions 
of  the  optic  thalami  involving  the  internal  capsule  may  produce  disturbances 
of  motion  and  of  sensation  upon  the  opposite  side  of  the  body,  and  in  some 
cases  hemianopsia.  Lesions  of  the  pons  may  produce  palsies  of  the  cranial 
nerves  on  the  same  side  of  the  body,  with  paralysis  of  the  extremities  upon 
the  opposite  side. 

The  Cerebellum. — Lesions  of  the  cerebellum  produce  disturbances  of  the 
equilibrium  of  the  body  when  the  patient  walks,  notably  if  the  median  lobe  is 
involved.  Such  are  staggering,  vertigo,  and  muscular  ataxia  of  the  extremities. 
If  the  median  lobe  is  involved  the  symptoms  are  bilateral.  If  a  lateral  lobe  is 
involved  the  symptoms  will  be  chiefly  upon  one  side  of  the  body :  when  walk- 
ing, these  patients  are  apt  to  stagger  toward  the  affected  side,  or  even  to  fall 
in  that  direction.  Nystagmus  and  paralyses  of  the  muscles  moving  the  eye 
are  common. 

From  the  above  briefly  stated  data  the  location  of  brain  lesions  must  be, 
in  part,  derived.  The  general  signs  and  symptoms  of  brain  lesions  are  head- 
ache, vomiting  without  nausea,  vertigo,  optic  neuritis  (choked  disk),  convul- 
sions, together  with  stupor  or  coma  of  any  grade.  The  focal  motor  symptoms 
are  partly  irritative  (muscular  contractions  or  attacks  of  Jacksonian  epilepsy ) 
and  partly  destructive — i.  e.,  paralyses  of  groups  of  muscles,  or  hemiplegia. 
From  the  situation  of  the  spasms  or  paralyses  it  is  sometimes  possible  to  locate 
the  lesion  in  the  corresponding  portion  of  the  motor  area.  In  some  cases,  as 
of  a  tumor  or  other  progressive  lesion,  the  symptoms  begin  with  irritation  and 
end  in  paralysis.  Sensory  symptoms  are  rarely  definite  enough  to  be  localized. 
The  interferences  with  speech  are  of  several  characters,  and  are  to  be  referred 
to  the  areas  already  indicated. 

Craxio-cerebral   Topography 

The  relation  of  the  fissures  of  the  brain  to  bony  landmarks  on  the  surface 
of  the  skull  has  been  worked  out  by  various  observers  according  to  various  plans. 
The  three  most  important  fissures,  from  a  surgical  point  of  view,  are  the  fissure 
of  Rolando,  the  fissure  of  Sylvius,  and  the  parieto-occipital  fissure. 

The  Fissure  of  Rolando. —  The  fissure  of  Eolando  may  be  located  as  follows: 
A  line  is  laid  down  from  the  root  of  the  nose  backward,  over  the  middle  line 
of  the  head  to  the  occipital  protuberance.  Measure  to  a  point  0.557  of  this 
distance  along  this  line  backward,  from  the  root  of  the  nose :  this  point  corre- 
sponds to  the  upper  end  of  the  Rolandic  fissure.  From  this  point  the  fissure 
rims  downward  and  forward  a  distance  of  about  three  and  one  half  inches, 
making  an  angle  of  sixty-seven  degrees  with  the  median  line  of  the  head.     In 


422  INJURIES   AND   DISEASES    OF   THE   BRAIN 

making  the  measurements  two  graduated  strips  of  metal  are  used.  One  strip 
is  fastened  to  the  other  at  an  angle  of  sixty-seven  degrees.  If  these  strips  are 
laid  upon  the  head  in  such  a  position  that  one  of  them  overlies  the  sagittal 
suture  while  their  junction  is  over  the  upper  end  of  the  Rolandic  fissure,  the 
second  strip  will  pass  downward  and  forward  at  an  angle  of  sixty-seven  degrees 
with  the  first,  and  will  overlie  the  course  of  the  fissure.  The  lower  third  of 
the  fissure  is  a  little  more  vertical  than  the  strip. 

The  Fissure  of  Sylvius  and  the  Parieto-occipital  Fissure. — These  two  fissures 
are  found  as  follows :  "  Lay  down  a  base  line  from  the  lower  margin  of  the 
orbit  to  the  auditory  meatus.  Lay  down  a  second  line  parallel  to  it  from  the 
external  angular  process  of  the  frontal  bone  backward  one  inch  and  a  quarter. 
Then  measure  upward  one  quarter  of  an  inch.  This  is  point  one.  Find  the 
most  prominent  part  of  the  parietal  eminence,  and  from  it  draw  a  line  down- 
ward perpendicular  to  the  base  line,  and  on  this  take  a  point  three  quarters 
of  an  inch  below  the  eminence ;  this  gives  point  two.  Join  these  two  points 
and  the  line  will  lie  over  the  fissure  of  Sylvius.  The  anterior  limb  of  the 
fissure  will  be  two  inches  behind  the  external  angular  process.  The  fissure  is 
about  four  inches  long.  To  find  the  parieto-occipital  fissure,  continue  the  line 
of  the  fissure  of  Sylvius  to  the  median  line.  At  their  junction  lies  this  fissure. 
Since  all  areas  now  open  to  surgical  operation  can  be  located  with  a  definite 
relation  to  these  three  fissures,  no  further  rules  are  necessary."  (Starr,  "  Or- 
ganic Nervous  Diseases,"  first  edition,  page  482.) 

Localization  of  Fissures. — It  is  customary  to  mark  the  position  of  the  fissure 
sought  upon  the  scalp  by  means  of  a  scratch  or  superficial  cut  with  a  scalpel. 
The  several  points  may  also  be  marked  upon  the  skull  itself  with  the  edge  of 
a  chisel  or  punch,  and  the  brain  exposed  by  raising  an  osteoplastic  flap  or  by 
making  one  or  more  trephine  openings,  enlarged  with  a  rongeur  as  may  be 
necessary.  Aseptic  technic  permits  large  osteoplastic  flaps  to  be  raised  with 
safety.  The  topography  of  the  brain  is  thus  more  readily  recognized.  A  num- 
ber of  forms  of  apparatus  have  been  devised  for  the  ready  localization  of  the 
important  fissures.  Among  the  most  complete  is  that  of  Kronlein.  A  number 
of  ingenious  methods  have  been  devised  by  German,  English,  French,  and 
American  surgeons  for  the  determination  of  the  relations  between  the  various 
convolutions  of  the  brain  and  definite  points  upon  the  surface  of  the  skull. 
For  a  full  description  of  these  the  reader  is  referred  to  the  very  complete  work 
of  A.  Chipault.  It  is  to  be  remembered  that  at  the  present  time  small  trephine 
openings  are  rarely  used  when  operating  upon  the  brain.  The  present  practice 
is  to  make  a  large  osteoplastic  flap,  and  thus  to  expose  so  large  an  area  of 
the  brain  that  small  errors  in  the  situation  of  the  incisions  are  unimportant. 
The  method  of  Kronlein  is  complete  and  satisfactory.  A  cut  of  the  apparatus 
used  is  here  given,  together  with  a  short  description  of  the  lines  and  angles 
as  constructed  upon  the  skull. 

The  description  is  here  given  nearly  in  the  words  of  the  originator  of  the 
method.    Five  lines  are  used  as  a  basis  for  the  plan.     They  are : 


GENERAL   CONSIDERATIONS 


423 


1.  The  base  line,  or  German  horizontal  line.  Ear-orbital  line  (linea  hori- 
zontalis,  auriculo-orbitalis) . 

2.  The  upper  horizontal  line    (linea   horizontalis  supra-orbitalis). 

3.  The  anterior  vertical  line   (linea  verticalis  zygomatica). 

4.  The  middle  vertical  line    (linea  verticalis  articnlaris). 

5.  The  posterior  vertical  line   (linea  verticalis  retromastoidea). 

6.  The  linea  Rolandi  obliqua. 

7.  The  linea  Sylvii  obliqua. 

The  points  upon  the  skull  from  which  these  lines  are  to  be  drawn  are  easily 
found.     The  lines  are  drawn  as  follows: 

(1)  The  base  line.  Through  the  inferior  border  of  the  orbit  and  the  supe- 
rior border  of  the  auditory  meatus.  (2)  The  upper  horizontal  line.  Through 
the  upper  border  of  the  orbit  parallel 
to  the  base  line.  (3)  The  anterior 
vertical  line.  From  the  middle  of 
the  zygoma  upward  at  right  angles 
to  the  base  line.  (4)  The  middle 
vertical  line.  From  the  head  of  the 
articular  process  of  the  inferior  max- 
illa upward  at  right  angles  to  the 
base  line.  (5)  The  posterior  vertical 
line.  From  the  most  posterior  point 
of  the  base  of  the  mastoid  process  up- 
ward at  right  angles  to  the  base  line. 
The  two  oblique  lines  are  secondary 
constructions.  They  are  drawn  as 
follows:  (6)  The  linea  Roland i.  The 
line  of  the  Rolandic  fissure  from  the 
point  of  intersection  of  the  anterior 
vertical  line  with  the  superior  hori- 
zontal line  to  the  point  where  the 
posterior  vertical  line  meets  the  sagit- 
tal suture  (middle  line  of  the  head). 
(7)  The  linea  Sylvii  of  the  fissure  of 

Sylvius  is  a  line  corresponding  to  half  the  angle  made  by  the  Rolandic  line 
and  the  superior  horizontal  line,  and  prolonged  backward  until  it  meets  the 
posterior  vertical  line. 

In  the  diagram  (Fig.  149)  the  letters  have  the  following  significance:  K, 
point  of  division  of  the  fissure  of  Sylvius.  S,  upper  end  of  the  fissure  of  Syl- 
vius. R,  lower  end  of  the  Rolandic  fissure.  P,  upper  end  of  the  Rolandic  fis- 
sure. K  and  K1,  points  for  the  application  of  the  trephine  to  reach  the  sources 
of  hemorrhage  in  rupture  of  the  middle  meningeal  artery.  A,  By  K1,  M}  quad- 
rilateral area  in  which,  according  to  von  Bergmann,  the  skull  may  be  resected 
by  an  osteoplastic  flap  to  reach  abscesses  in  the  temporal  lobe  of  the  brain  fol- 


Fig    148 — Kroxlein's  Craxjometer. 


424 


INJURIES   AND    DISEASES    OF    THE   BRAIN 


lowing  otitic  disease.  The  several  lines  and  angles  of  the  diagram  may- 
be constructed  upon  the  head  without  the  aid  of  special  apparatus,  hut  the 
method  is  rendered  simpler  and  easier  by  the  use  of  Kronlein's  craniometer, 

an  instrument  applied  to  the 
head  (as  seen  in  the  illustra- 
tion) ;  from  what  has  preced- 
ed, no  further  explanation  of 
its  use  is  required. 

INJURIES   OF  THE   BRAIN 

Concussion  of  the  Brain, 
Commotio  cerebri,  Cerebral 
Shock. — By  these  terms  we 
designate  the  condition  fol- 
lowing generalized  injuries  to 
the  head  in  which  no  recog- 
nizable lesion  of  the  brain  is 
discoverable,  but  which  pre- 
sent symptoms  of  temporary 
impairment  or  abolition  of  the 
functions  of  the  brain  as  a 
whole.  The  symptoms  appear 
at  once  on  receipt  of  a  blow  or 
fall  upon  the  head.  The  pa- 
tient suddenly  becomes  uncon- 
scious ;  he  is  stunned  and  falls 
inanimate.  The  unconscious- 
ness may  be  momentary  or 
prolonged.  In  mild  cases  re- 
covery begins  at  once;  the  pa- 
tient regains  consciousness, 
but  is  giddy,  weak,  has  head- 
ache, is  dull  and  confused  for 
some  minutes  or  hours.  The 
occurrences  immediately  pre- 
ceding the  accident  and  the  accident  itself  are  forgotten.  In  more  severe 
cases  unconsciousness  lasts  for  minutes  or  hours ;  shock  is  more  pronounced ; 
the  surface  is  pale ;  the  pulse  is  slow,  feeble,  and  compressible ;  respiration 
is  superficial,  irregular,  or  stertorous.  The  conjunctiva  is  insensitive  and 
normally  painful  irritations  of  the  skin  produce  no  reaction.  The  pupils 
are  equal,  normal,  contracted  or  dilated,  but  responsive  to  light.  Repeated 
vomiting  is  common.  There  may  be  convulsive  twitchings  of  the  limbs.  Re- 
covery is  gradual.     Headache,  confusion  of  mind,  muscular  ataxia,  retention 


Z       A  M 

Fig.  149.  —  Diagram  of  Lines  and  Angles  Constructed 
upon  the  Skull,  for  the  Location  of  the  Convolu- 
tions and  Fissures.     (Kronlein.) 


INJURIES    OF    THE    BRAIN 


425 


or  incontinence  of  urine  and  feces  may  lie  present.  For  a  time  the  patient  may- 
be wholly  or  partly  aphasic.  The  symptoms  gradually  pass  away  after  hours 
or  days.  During  recovery  the  patient  lies  in  bed  on  his  side  in  a  position  of 
general  flexion ;  he  is  irritable  and  does  not  wish  to  be  disturbed.  During  this 
time  the  face  may  be  flushed,  the  eyes  bright  and  suffused.  The  pulse  is  rapid 
and  of  high  tension.  The  sooner  and  more  complete  the  return  to  consciousness, 
the  more  probable  it  is  that  the  condition  is  merely  that  of  cerebral  shock. 


Fig.  150. — Chipault's  Method  of  Cranio-cerebral  Localization  by  Angles  and  Measurements. 

(Kindness  of  Dr.  Frank  Hartley.) 

This  method  is  dependent  on  a  percentage  basis,  and  therefore  is  particularly  accurate  regardless  of 
how  sex,  age,  or  race  may  vary  the  size  or  shape  of  the  head.  The  distance  from  the  nasion  or  naso- 
frontal suture  over  the  midline  of  the  vertex  to  the  inion  or  external  occipital  protuberance  is  measured 
and  marked  on  the  scalp.  On  this  line,  always  measuring  from  its  anterior  end  or  nasion,  the  follow- 
ing percentages  of  its  length  are  marked:  45  per  cent,  55  per  cent,  70  per  cent,  80  per  cent,  and  95  per 
cent.  The  retro-orbital  tubercle,  a  small  projection  of  bone  on  the  posterior  border  of  the  frontal  process 
of  the  malar  bone,  is  located  and  its  position  marked  on  the  scalp.  A  line  is  drawn  from  this  retro- 
orbital  tubercle  to  the  70  per  cent  point,  measured  and  divided  into  tenths.  The  junction  of  the  second 
and  third  tenths  is  joined  to  the  45  per  cent  point  and  the  junction  of  the  third  and  fourth  is  joined 
to  the  55  per  cent  point.  The  retro-orbital  tubercle  is  also  joined  to  the  80  per  cent  point  and  to  the 
95  per  cent  point. 

The  line  to  the  45  per  cent  corresponds  to  the  precentral  fissure. 

The  line  to  the  55  per  cent  corresponds  to  the  Rolandic  fisstire. 

The  line  to  the  70  per  cent  point  corresponds  to  the  Sylvian  fissure. 

The  line  to  the  SO  per  cent  point  corresponds  to  the  superior  temporo-sphenoidal  fissiire. 

The  line  to  the  95  per  cent  point  corresponds  to  the  lateral  sinus. 

For  more  accurate  and  detailed  localization  all  these  lines  may  be  divided  into  tenths. 


When  the  unconsciousness  is  prolonged  for  hours  or  days,  the  diagnosis  of  mere 
cerebral  shock  can  hardly  be  made.  It  is  probable  that  contusion  or  laceration 
of  the  brain  or  greater  or  less  severity  is  present. 


426  INJURIES   AND   DISEASES    OF   THE   BRAIN 

Compression  of  the  Brain. — Compression  of  the  brain  may  be  due  to  any- 
thing which  causes  a  sudden  continuous  increase  of  intracranial  tension — effused 
blood,  displaced  fragments  of  bone  in  depressed  fractures  of  the  skull,  foreign 
bodies,  and  inflammatory  exudates.  As  the  result  of  accidental  injuries  the 
symptoms  of  compression  of  the  brain  are  usually  associated  with  those  of  cere- 
bral shock,  or  of  contusion  or  laceration  of  the  brain.  In  pure  cases  of  com- 
pression— such  as  sometimes  accompany  rupture  of  the  middle  meningeal  artery 
and  intracranial  hemorrhage — a  distinct  interval  occurs  between  the  accident 
and  the  onset  of  typical  symptoms ;  such  may  be  hours  or  days. 

Symptoms. — The  symptoms  may  be  described  under  two  heads :  Symptoms 
of  irritation,  followed  by  the  true  symptoms  of  compression.  At  once,  after 
the  accident,  the  patient  suffers  from  headache;  he  is  often  excited  and  irri- 
table. The  face  is  sometimes  flushed;  the  pulse  is  slow  and  of  high  tension. 
The  pupils  are  equal  and  often  contracted ;  nausea  and  vomiting  are  common. 
The  patient  gradually  becomes  dull  and  stupid,  and  finally  falls  into  a  deep 
sleep,  which  is  followed  by  coma.  With  the  onset  of  coma  the  second  set  of 
symptoms  are  developed.  They  consist  of  the  coma,  of  changes  in  the  pupils 
of  the  eyes ;  the  pupil  on  the  side  of  the  injury  is  at  first  contracted,  and  later 
dilated  and  wider  than  that  of  the  other  eye.  There  occur  also  paralyses, 
either  limited  to  one  particular  limb  or  group  of  muscles,  or  hemiplegia,  or 
paraplegia.  The  oculo-motor  nerve  is  often  affected.  There  may  be  squint  or  a 
slow  rolling  of  the  bulb  of  the  eye.  Observation  of  the  fundus  of  the  eye 
frequently  shows  choked  disk.  If,  as  is  rarely  the  case,  the  compression  of  the 
brain  is  very  sudden,  there  may  be  convulsive  movements  of  the  extremities. 
The  heart  beats  slowly,  respiration  is  slow  and  stertorous,  and  may  be  irregular. 
As  a  fatal  issue  approaches,  respiration  may  cease  for  a  minute  or  more,  and 
then  be  resumed.  The  heart  may  continue  to  beat  for  several  minutes  after 
respiration  has  ceased.  Inequality  and  insensitiveness  of  the  pupils  indicates 
a  serious  or  high  degree  of  compression.  If  they  are  equal,  or  continue  to 
respond  to  light,  the  compression  is  not  severe.  The  more  widespread  the 
paralysis  the  larger  the  hemorrhage.  A  limited  paralysis  indicates  hemorrhage 
between  the  dura  and  the  skull.  A  widespread  paralysis,  hemorrhage  beneath 
the  dura.     The  paralyses  are  on  the  side  opposite  the  compression. 

Injuries  of  the  Blood-vessels  of  the  Brain. — Injuries  of  the  Sinuses. — In- 
juries of  the  sinuses  of  the  brain  occur  as  the  result  of  fractures  or  of  wounds, 
such  as  gunshot  or  stab  wounds  of  the  skull.  They  may  be  produced  by  de- 
pressed bone  fragments,  which  lacerate  the  Avail  of  the  sinus ;  or  ruptured  by  dis- 
placements of  bone  in  fractures  of  the  skull,  or  during  labor.  If  the  wound  of 
the  sinus  communicates  with  an  external  wound,  there  will  be  venous  bleeding, 
which  is  usually  easily  controlled  by  pressure.  The  superior  longitudinal  sinns 
is  most  often  wounded,  and  the  transverse  sinus  rarely.  If  the  injury  is  sub- 
cutaneous, so  that  the  blood  cannot  escape,  it  may  accumulate  between  the 
dura  and  the  skull,  or  beneath  the  dura,  and  produce  symptoms  of  compres- 
sion of  the  brain.     The  onset  of  the  symptoms  is  much  slower  than  after 


INJUEIES    OF   THE   BKAIN  427 

arterial  hemorrhage,  and  of  less  intensity,  indeed,  in  many  cases  of  injury  to 
the  sinuses,  the  symptoms  of  compression  are  entirely  wanting. 

Injury  of  the  Arteries  in  the  Cranial  Cavity. — Hemorrhage,  or 
bleeding  from  the  middle  meningeal  artery,  has  already  been  described  under 
Fractures  of  the  Skull. 

Injury  of  the  Internal  Carotid  Artery. — On  account  of  its  deeply 
placed  position,  the  internal  carotid  artery  is  much  less  often  wounded  than 
the  middle  meningeal.  The  artery  may,  however,  be  injured  by  a  sharp  frag- 
ment of  bone  in  fractures  of  the  base  of  the  skull;  as  the  result  of  gunshot 
wounds ;  occasionally  from  stab  wounds  through  the  orbit  which  penetrate  the 
skull.  If  the  artery  be  wounded  in  the  cavernous  sinus,  an  arterio-venous  aneu- 
rism may  develop  and  produce  a  pulsating  exophthalmos.  Injuries  of  the 
carotid  in  this  situation  are  sometimes  accompanied  by  paralysis  of  the  abdu- 
cens  or  motor  oculi  nerve.  Generally  speaking,  rupture  of  the  internal  carotid 
artery  is  a  rapidly  fatal  injury  from  intracranial  hemorrhage  and  the  symp- 
toms of  pressure  upon  the  brain,  sudden  coma,  and  death. 

Intracranial  Hemorrhage  between  the  Dura  and  the  Pia. — Intra- 
cranial hemorrhage  between  the  dura  and  the  pia  occurs  as  the  result  of  injuries 
to  the  head,  notably  those  involving  laceration  of  the  brain  substance.  It  occurs 
usually  from  small  blood-vessels  or  from  a  venous  sinus.  The  amount  of  blood 
extravasated  may  be  large  or  small.  The  blood  spreads  itself  over  the  sur- 
face of  the  brain,  and  its  accumulation  may  be  followed  by  the  symptoms  of 
compression.  These  symptoms  are  much  more  slowly  developed,  and  .of  less 
intensity  than  are  observed  after  rupture  of  the  middle  meningeal  artery.  If 
the  extravasations  are  moderate  in  amount,  and  do  not  invade  one  or  other  of 
the  areas  of  the  cortex  presiding  over  some  definite  function,  they  may  produce 
no  symptoms  at  all.  Rupture  of  one  of  the  larger  arteries  of  the  brain  itself 
is  usually  attended  by  a  rapidly  fatal  result  with  the  symptoms  of  sudden  com- 
pression of  the  brain. 

Injuries  of  the  Cranial  Nerves  within  the  Skull. — When  the  cranial  nerves 
are  injured  within  the  skull  paralyses  occur  on  the  same  side  of  the  body  as 
the  injury. 

The  Olfactory  ISTerve. — The  olfactory  nerve  is  sometimes  ruptured 
in  fracture  of  the  base  of  the  skull  involving  the  anterior  fossa,  occasion- 
ally by  wounds,  or  falls  upon  the  forehead,  sometimes  by  falls  upon  the 
occiput.  Injuries  of  the  olfactory  nerve  are  attended  by  the  loss  or  diminu- 
tion of  the  sense  of  smell.  The  sense  of  taste  is  so  much  a  part  of  the 
sense  of  smell  that  the  loss  of  the  latter  is  attended  by  a  diminution  of 
the  former. 

The  Optic  Nerve. — Complete  division  of  the  optic  nerve  is  attended  by 
blindness  in  the  corresponding  eye.  Contusion  of  the  nerve  or  pressure  by  a 
blood  clot  may  be  wholly  recovered  from.  (See  case  described,  p.  409,  pistol- 
shot  wounds  of  the  anterior  fossa  of  the  skull  in  which  there  was  also  ptosis 
and  dilated  pupil,  significant  of  injury  of  oculo-motor  nerve.) 


428  INJURIES   AND   DISEASES    OF   THE   BRAIN 

The  Oculomotor  Nerve. — The  third  nerve  may  be  injured  by  the  pres- 
sure of  the  forceps  during  parturition  and  as  the  result  of  fractures  of  the 
anterior  fossa  and  of  wounds  of  the  orbit.  The  symptoms  of  paralysis  of  the 
third  nerve  are  ptosis — i.  e.,  falling  of  the  upper  eyelid,  dilatation  of  the  pupil, 
with  loss  of  reflexes  both  for  light  and  distance.  The  eyeball  is  turned  out- 
ward and  a  little  downward. 

Trochlear  Nerve. — Injury  of  the  trochlear  nerve,  with  the  production 
of  diplopia,  has  been  occasionally  observed  after  severe  injuries  of  the  head. 

The  Fifth  Pair  of  Cranial  Nerves. — The  fifth  pair  of  cranial  nerves  is 
rarely  injured  alone  in  fractures  of  the  base  of  the  skull,  but  its  injury  is  very 
commonly  associated  with  injuries  of  the  other  pairs  of  cranial  nerves  in  these 
fractures.  If  the  paralysis  be  complete,  the  insensitiveness  of  the  conjunctiva 
leads  to  trophic  ophthalmia,  probably  because  the  conjunctiva,  being  insensitive, 
the  pressure  of  foreign  bodies  and  other  sources  of  irritation  is  not  observed 
by  the  patient.  Also,  it  is  believed,  on  account  of  the  trophic  nerves  which 
accompany  the  fibers  of  the  fifth  pair. 

Paralysis  of  the  Abducens  Nerve. — Paralysis  of  the  abducens  nerve 
is  infrequent.  It  may  accompany  the  formation  of  an  arterio-venous  aneurism 
between  the  internal  carotid  and  the  cavernous  sinus.  The  symptom  of  paraly- 
sis of  the  sixth  or  abducens  nerve  is  internal  strabismus. 

The  Facial  Nerve. — The  facial  nerve  is  not  infrequently  injured  dur- 
ing instrumental  delivery,  but  the  paralysis  is  not  permanent.  It  is  very  often 
injured  in  fractures  of  the  base  of  the  skull  which  pass  through  the  petrous 
portion  of  the  temporal  bone,  and  the  injury  is  commonly  associated  with  that 
of  the  nerve  of  hearing.  In  these  cases  the  lesion  is  almost  always  upon  one 
side  only.  The  paralysis  is  quite  apt  to  be  permanent.  Erb  states,  that  if  the 
soft  palate  is  not  paralyzed,  then  the  facial  is  injured  below  the  geniculate 
ganglion — that  is  to  say,  below  the  point  of  origin  of  the  great  superficial 
petrosal  nerve.     If  the  soft  palate  is  paralyzed  the  injury  is  above  the  ganglion. 

The  Acoustic  Nerve. — Injuries  of  the  acoustic  nerve  occur  less  often 
in  fractures  of  the  base  of  the  skull  than  is  the  case  with  the  facial.  Loss  of 
the  sense  of  hearing  may,  however,  occur  from  hemorrhage  within  the  labyrinth, 
or  within  the  middle  ear,  without  the  presence  of  fracture.  If  facial  paralysis 
and  deafness  exist  upon  one  side,  with  paralysis  of  the  sense  of  taste,  the  nerves 
have  been  injured  in  the  neighborhood  of  the  internal  meatus  (Tillmans).  One 
case  of  injury  of  the  glossopharyngeal  nerve  is  related  by  Pirogoff.  Following 
a  blow  upon  the  neck,  there  occurred  disturbances  of  speech  and  swallowing, 
the  root  of  the  tongue  ulcerated.  Death  occurred  from  edema  of  the  glottis. 
The  autopsy  showed  a  hemorrhage  in  the  form  of  a  clot  in  the  root  of  the  glosso- 
pharyngeal nerve.  Paralyses  of  the  other  cranial  nerves  as  the  result  of  injury 
within  the  skull  are  exceedingly  rare. 

Contusion,  Laceration,  and  Wounds  of  the  Brain. — Contusion  and  laceration 
of  the  substance  of  the  brain  occur  as  the  result  of  direct  or  indirect  violence 
applied  to  the  skull,  or  to  the  brain  itself,  as  the  result  of  blows,  falls,  gun- 


INJURIES   OF   THE   BRAIN  429 

shot  or  other  wounds.  The  severer  forms  are  nearly  always  complicated  by 
fracture  of  the  skull.  The  lesions  vary  from  the  production  of  minute  punctate 
hemorrhages  into  the  suhstance  of  the  brain,  to  disorganization  of  the  entire 
brain,  or  of  a  limited  area  thereof,  of  any  size.  The  injury  to  the  brain  may 
be  at  the  point  of  application  of  the  force  or  at  a  distant  point,  sometimes  upon 
the  opposite  side  of  the  head. 

Symptoms. — The  symptoms  depend  upon  the  portion  of  the  brain  injured. 
As  has  been  pointed  out,  injuries  or  destruction  of  certain  parts  of  the  brain 
are  not  necessarily  accompanied  by  recognizable  symptoms.  The  symptoms  of 
cerebral  shock  are  common,  and  are  often  combined  with  those  of  intracranial 
bleeding  and  compression  of  the  brain.  There  are,  moreover,  special  symptoms 
when  certain  parts  of  the  brain  are  involved.  These  will  correspond  with  the 
areas  presiding  over  motion,  sensation,  vision,  speech,  etc. — as  described  in  the 
section  on  Cerebral  Localization.  In  general,  it  may  be  said  that  cases  of 
injury  to  the  head — followed  by  localized  palsies,  not  presenting  symptoms  of 
compression — are  due  to  contusion  and  laceration  of  the  brain.  The  paralyzed 
muscles  undergo  subsequent  contracture.  Soon  after  the  injury  clonic  spasms 
may  occur.  Broncho-pneumonia  is  a  common  complication,  due  to  aspiration 
of  vomited  matter,  etc.,  into  the  lungs  during  unconsciousness.  Subcutaneous 
injuries  of  the  brain  usually  run  an  aseptic  course.  If  open  wounds  exist,  and 
are  infected,  the  symptoms  of  meningitis,  sinus  thrombosis,  abscess  of  the  brain, 
etc.,  are  added. 

Interesting  and  important  as  is  the  topic,  want  of  space  forbids  a  discus- 
sion of  the  details  of  cerebral  localization  in  extenso.  The  reader  is  referred 
especially  to  "  A  Handbook  of  Practical  Surgery,"  vol.  i,  E.  von  Bergmann ; 
Starr,  "  Organic  Nervous  Diseases  "  ;  Gowers,  Chipault,  and  Bailey.  A  knowl- 
edge of  the  physiology  of  the  brain  will,  in  general,  suffice  for  a  correct  inter- 
pretation of  local  symptoms. 

As  has  already  been  noted,  foreign  bodies — notably  bullets  of  small  caliber 
fired  at  low  velocities — may  remain  indefinitely  in  the  brain  and  produce  no 
symptoms;  their  location  can  be  determined  by  means  of  X-ray  pictures.  On 
the  other  hand,  abscess  of  the  brain  may  cause  death  after  a  long  interval 
of  apparent  immunity.  In  other  cases  the  injured  portion  of  brain  may 
undergo  softening  due  to  changes  (fatty  degeneration)  in  the  blood-vessels. 
Such  changes  may  be  progressive  and  finally  interfere  with  the  nutrition  of 
portions  of  the  brain  presiding  over  vital  functions;  paralyses  or  fatal  coma 
follow.  The  symptoms  resemble  those  of  abscess  of  the  brain.  Some  years  ago 
I  saw  such  a  case  in  the  person  of  a  distinguished  medical  man  who  was  brought 
to  the  hospital  comatose,  with  fracture  of  the  base.  After  many  weeks  of 
total — later  partial — unconsciousness,  deafness  in  one  ear,  facial  paralysis,  he 
apparently  became  convalescent.  Rather  sudden  fatal  coma  supervened.  The 
autopsy  showed  a  fracture  of  the  base  through  the  middle  and  anterior  fossa? 
of  the  skull  upon  one  side,  and  a  large  area  of  red  softening  upon  the  oppo- 
site side  of  the  brain  which  had  extended  deeply  in  from  the  cortex  to  involve 


430 


INJURIES   AND   DISEASES    OF   THE   BRAIN 


the  pons  and  a  portion  of  the  medulla.  Following  contusion  of  the  brain, 
epilepsy  and  psychoses  are  not  uncommon.  Epilepsy,  especially,  follows  in- 
juries of  the  medulla  and  the  motor  area  of  the  cortex. 

Prolapse  of  the  Brain  through  a  Wound. — Prolapse  of  the  brain  through 
a  wound  sometimes  occurs  after  compound  fractures  of  the  vertex  with  loss 
of  substance  and  of  wound  of  the  dura.  The  character  of  the  brain  tissue  is 
easily  recognized.  True  hernia  of  the  brain  may  occasionally  remain  (en- 
cephalocele).  Ordinarily  the  protruding  mass  constitutes  what  is  known  as 
fungus  cerebri.     The  exposed  brain  becomes  covered  by  granulation  tissue 


Fig.   151. — Fungus  Cerebri  Following  an  Operation  for  Compound  Depressed  Fracture  of 
the  Skull.     (Kindness  of  Dr.  J.  C.  Ayer.) 

and  forms  a  dirty-white,  pink,  or  red  f ungating  tumor  which  projects  above 
the  level  of  the  scalp,  and  may  pulsate  while  it  is  small ;  later,  pulsation  usually 
disappears.  It  is  painless  and  insensitive;  bleeds  readily.  If  infected  it  may 
become  gangrenous  or  cause  meningitis,  etc.  Firm  pressure  upon  it  may 
cause  mild  symptoms  of  cerebral  compression,  giddiness.  The  tumor  increases 
in  size  on  coughing,  sneezing,  straining,  etc.  After  healing  takes  place  a 
marked  depression  is  left  at  the  site  of  the  former  protrusion.  In  rare  cases 
a  protrusion  remains  after  healing  is  complete. 

Inflammation  of  the  Dura  Mater — Pachymeningitis. — Inflammation  may 
occur  on  the  outer  or  internal  surface  of  the  dura — pachymeningitis  externa 
and  pachymeningitis  interna — or  both.  Purulent  inflammation  of  the  dura 
occurs  as  the  result  of  infected  fractures  of  the  skull,  and  of  suppurative 
processes  of  the  soft  parts  of  the  head  and  face  and  orbit,  not  infrequently 


INJURIES    OF   THE   BRAIN  431 

as  a  complication  of  acute  or  chronic  suppuration  of  the  middle  ear,  or  as  an 
extension  from  purulent  infection  of  the  cranial  bones  following  injury  or 
disease;  sinus  phlebitis,  inflammation  of  the  pia,  encephalitis,  and  abscess  of 
the  brain  are  common  associated  lesions. 

Pachymeningitis  externa  alone,  if  the  purulent  exudate  be  large  in  amount, 
may  produce  symptoms  of  compression  of  the  brain.  The  purulent  collection 
may  be  protected  from  extension  by  adhesions  and  the  formation  of  granu- 
lation tissue,  and  remain  latent  for  an  indefinite  time.  Headache,  fever,  ten- 
derness on  pressure,  very  rarely  focal  symptoms,  may  be  present.  There  will 
nearly  always  be  an  infected  wound  or  fracture  and  a  local  suppurative  process, 
middle-ear  disease,  caries  or  necrosis  of  the  cranial  bones,  etc.  The  impor- 
tance of  pachymeningitis  arises  largely  from  the  associated  lesions  to  which 
it  gives  rise — sinus  phlebitis,  meningitis,  abscess  of  the  brain,  etc. 

Inflammations  of  the  Venous  Sinuses  of  the  Dura  Mater. — Purulent  infection 
of  the  sinuses  of  the  dura  mater  occurs  as  the  result  of  infectious  processes 
of  the  soft  parts  of  the  head  and  face,  infected  fractures  of  the  skull,  and  puru- 
lent infection  of  the  cranial  bones.  The  most  common  cause  of  all  is  sup- 
purative inflammation  of  the  middle  ear  and  mastoid  process  of  the  temporal 
bone,  acute  or  chronic.  It  is  seldom  that  the  symptoms  of  sinus  inflammation 
exist  alone;  they  are  nearly  always  Combined  with  those  of  the  middle  ear 
and  mastoid  disease,  or  with  meningitis,  abscess  of  the  brain,  an  infected 
fracture,  erysipelas,  anthrax,  a  phlegmon  of  the  face  and  scalp,  or  some  other 
septic  condition.  The  regular  ending  of  purulent  inflammation  of  the  sinuses 
is  pyemia. 

Inasmuch  as  inflammations  of  the  middle  ear  and  the  mastoid  process  are 
the  causative  factor  in  two  thirds  of  the  cases,  the  lateral  sinus  is  more  often 
affected  than  any  other.  The  wall  of  the  sinus  becomes  infected  by  continuity 
of  structure  through  its  wall  (thrombophlebitis)  or  a  minute  vein  in  the  site 
of  the  primary  focus  becomes  infected  and  thrombosed  and  the  thrombosis 
spreads  along  the  vein  to  the  sinus.  The  general  symptoms  are  those  of 
pyemia — chills,  fever,  sweating,  etc.  In  the  early  stages  the  symptoms  refer- 
able to  the  brain  are  those  of  irritation  and  compression — headache,  sometimes 
followed  by  delirium  and  coma,  nausea  and  vomiting.  Later,  as  a  result  of  a 
complicating  meningitis,  there  may  be  convulsions  and  paralyses. 

In  the  absence  of  meningitis  or  abscess  of  the  brain,  the  process  may  run 
its  course  as  a  pyemia  without  the  development  of  cerebral  symptoms.  In 
some  instances  the  thrombosis  may  extend  downward  into  the  internal  jugular 
vein,  usually  not  lower  than  its  upper  third,  which  may  sometimes  be  felt  as 
a  hard  cord  along  the  anterior  border  of  the  sterno-mastoid  muscle.  The 
involvement  of  the  cavernous  sinus  is  commonly  attended  by  congestion  of 
the  eyeball,  sometimes  by  moderate  exophthalmos  and  engorgement  of  the 
superficial  veins  of  the  eyelids  and  forehead.  The  nerves  in  the  vicinity  of 
the  sinus  may  be  partly  or  totally  paralyzed — in  this  case  the  oculo-motor, 
the  trochlear,  the  abducens,  and  the  first  branch  of  the  fifth  pair.     The  move- 


432  INJURIES   AND   DISEASES    OF   THE   BKAIN 

ments  of  the  tongue  may  also  be  affected  by  pressure  upon  the  hypoglossal 
nerve. 

When  the  disease  begins  in  the  middle  ear  or  the  mastoid  process  the 
Streptococcus  pyogenes  and  the  pneumococcus  are  the  organisms  most  often 
found.  There  will  be  the  history  of  an  acute  or  chronic  inflammation  of  the 
middle  ear,  discharge  from  the  external  ear,  and  deafness,  tenderness  and 
swelling  over  the  mastoid  process  (see  Ear),  sometimes  facial  paralysis.  In 
some  cases  the  infection  of  the  vein  is  accompanied  by  the  production  of  a 
localized  abscess  either  extra-dural  or  subdural;  in  such  cases  there  will  be 
severe  headache,  sometimes  choked  disk,  the  symptoms  of  pressure  upon,  or 
irritation  of,  the  pneumogastric,  a  rapid  or  slow  pulse.  Infection  of  the  supe- 
rior longitudinal  sinus  occurs  especially  after  gunshot  wounds  and  infected 
fractures  of  the  skull;  there  are'  rarely  any  localizing  symptoms  other  than 
those  of  meningitis  and  pyemia. 

Primary  Meningitis — Acute  Suppurative  Inflammation  of  the  Pia  Mater 
(Leptomeningitis). — Primary  meningitis  occurs  most  often  as  the  result  of 
direct  traumatisms  to  the  head  (infected  fractures,  stab  and  gunshot  wounds, 
and  the  like),  rarely  as  the  result  of  hematogenous  infection.  While  puru- 
lent inflammations  of  the  external  surface  of  the  dura  tend  rather  to  remain 
localized,  those  of  the  pia  tend  to  spread  rapidly  and  to>  involve  a  large  part, 
or  even  the  entire  surface,  of  the  convexity  and  base  of  the  brain.  The  cases 
may  be  divided  into  two  types:  Those  in  which  infection  takes  place  at  the 
time  of  the  injury,  or  very  soon  thereafter,  and  those  in  which  the  pia  is 
not  infected  until  later,  during  the  healing  process,  and  thus  the  appearance 
of  symptoms  may  be  delayed  for  weeks  or  months — early  and  late  meningitis 
(Kronlein).     The  pyogenic  organisms  are  the  cause  of  the  infection. 

In  the  late  cases  the  conditions  favoring  the  occurrence  of  meningitis  are 
necrosis  of  the  injured  tissues,  imperfect  drainage,  the  presence  of  foreign 
bodies,  of  loose  splinters  of  bone,  sinus  thrombosis  and  phlebitis  (Kronlein). 
In  the  early  cases  the  pia  may  be  inflamed  a  few  hours  after  the  injury,  and 
thus  the  symptoms  are  often  combined  with  those  of  cerebral  concussion,  com- 
pression, or  contusion  and  laceration.  The  late  cases  are  frequently  compli- 
cated by  encephalitis,  purulent  softening  of  the  brain  and  abscess;  it  is,  there- 
fore, difficult  to  draw  a  typical  clinical  picture  of  meningitis. 

The  early  cases  usually  run  an  exceedingly  acute  course;  as  a  rule  the 
disease  ends  in  death  in  a  few  days.  In  many  instances  following  an  open 
injury  to  the  head,  usually  a  fracture,  the  patient  will  have  a  chill,  accom- 
panied by  a  rise  of  temperature  and  a  rapid  pulse,  headache,  nausea,  and 
vomiting.  He  will  be  very  restless  and  suffer  from  extreme  thirst,  the  pupils 
of  the  eyes  will  be  contracted,  the  restlessness  will  be  followed  by  delirium, 
and  the  delirium  by  stupor,  coma,  and  death.  There  may  be  no  localizing 
symptoms  whatever.  In  such  cases  the  locality  of  the  process  can  only  be 
inferred  from  the  situation  of  the  wound. 

In  other  cases  the  general  symptoms  will  be  accompanied  by  special  symp- 


THE   DISEASES    OF   THE   BRAIN  433 

toms  referable  to  some  particular  part  of  the  brain.  Muscular  rigidity  of 
one  or  more  limbs,  or  of  groups  of  r/fuscles,  notably  the  muscles  of  the  lwk 
of  the  neck  in  meningitis  involving  the  base  of  the  brain.  There  may  be 
convulsive  twitchings  or  clonic  convulsions  of  the  limbs,  or  evidences  of 
irritation  in  the  areas  supplied  by  one  or  other  of  the  cranial  nerves,  the  adbu- 
cens,  the  oculo-motor,  the  facial  nerves,  or  Cheyne-Stokes  respiration,  or 
difficulty  in  swallowing.  There  may  be  paralysis  of  an  extremity  or  hemi- 
plegia. It  may  thus  be  possible  to  say  that  the  meningitis  involves  one  or 
the  other  side  of  the  head,  or  is  more  intense  upon  the  convexity,  or  upon 
the  base  of  the  brain  (Kronlein).  The  course  of  the  disease,  once  inaugurated, 
is  as  acute  in  the  late  as  in  the  early  cases.  Purulent  meningitis  may  also 
occur  as  well  through  infection  of  wounds  in  the  mucous  membrane  of  the 
nose,  the  pharynx,  or  the  middle  ear,  complicating  fracture  of  the  base,  as 
from  wounds  and  fractures  upon  the  convexity  of  the  skull. 

Secondary  Meningitis. — In  addition  to  meningitis  from  wounds,  infection 
may  occur  secondarily,  by  continuity  of  structure,  or  through  the  medium  of 
the  blood  and  lymph  channels  during  acute  and  chronic  suppurative  processes 
of  the  soft  parts  or  the  bones  of  the  skull  and  face,  notably  the  middle  ear,  or 
occasionally  in  the  course  of  pyemia ;  the  symptoms  are  the  same  as  in  the  trau- 
matic form. 

THE    DISEASES    OF    THE    BRAIN 

Abscess  of  the  Brain. — Abscess  of  the  brain  may  be  either  acute  or  chronic, 
and  may  result  from  injuries,  infected  fractures  of  the  skull,  contusions  and 
lacerations  of  the  brain  which  become  infected,  or  as  the  result  of  diseases 
of  the  skull,  the  brain  or  its  membranes,  such  as  tuberculosis,  syphilis,  actino- 
mycosis, sometimes  in  the  course  of  pyemia  as  a  metastatic  process.  It  is  a 
very  frequent  complication  of  disease  of  the  middle  ear.  Acute  abscess  of 
the  brain  following  injury  may  be  simply  a  part  of  an  acute  meningitis, 
accompanied  by  septic  infection  and  purulent  softening  of  a  circumscribed 
portion  of  the  brain  infected  at  the  time  of  the  injury,  or  it  may  occur  some 
time  after  the  original  injury,  as  the  result  of  a  late  infection  of  a  contused 
and  lacerated  area  of  the  brain  substance.  If  such  an  area  communicates 
directly  and  freely  with  the  external  wound,  the  pus  may  be  discharged  exter- 
nally and  healing  by  granulation  is  possible.  In  some  cases  such  a  purulent 
collection  may  remain  encapsulated  for  an  indefinite  time,  and  produce  no 
symptoms  for  months,  or  years,  so  long  as  no  important  portion  of  the  brain 
is  invaded.  Sooner  or  later  the  abscess  may  increase  in  size  and  produce 
death  by  rupture  and  purulent  meningitis,  or  by  rupture  into  the  lateral  ven- 
tricle, or  by  invading  some  vital  portion  of  the  brain  tissue.  The  metastatic 
abscesses  of  the  brain,  occurring  in  the  course  of  pyemia,  may  be  single  or 
multiple,  and  give  rise  to~definite  symptoms,  or  not,  according  to  their  loca- 
tion.    Aside  from  traumatisms  to  the  head,  chronic  disease  of  the  middle  ear 

is  the  most  frequent  cause  of  abscess  of  the  brain. 
29 


434 


INJURIES   AND   DISEASES    OF    THE   BRAIN 


Symptoms. — The  symptoms  of  abscess  of  the  brain  depend  partly  upon  the 
locality  of  the  abscess  and  partly  upon  the  septic  nature  of  the  process  and 
partly,   although   rarely,   upon   the  production   of  compression   of  the   brain. 

When  a  brain  abscess  com- 
municates with  an  open 
fracture  of  the  skull,  which 
is  eyidently  infected  and 
discharging  pus,  its  loca- 
tion offers  no  difficulties. 
In  the  more  chronic  forms 
of  abscess,  persistent  local- 
ized headache  correspond- 
ing to  an  area  of  tender- 
ness upon  percussion,  the 
occurrence  of  irregular  at- 
tacks of  intermittent  fever, 
are  sometimes  important 
aids  in  the  diagnosis.  Lo- 
calizing symptoms  of  de- 
struction of,  or  pressure 
upon,  definite  portions  of 
the  brain,  may  be  present 
or  absent,  according  to  the 
situation  of  the  abscess ;  if 
present,  they  will  vary  ac- 
cording to  the  locality  of 
the  abscess.  (See  Cerebral 
Localization.)  The  diag- 
nosis of  acute  abscess  of 
the  brain  following  injury  may  be  impossible  on  account  of  the  complicating 
conditions,  meningitis,  etc. 

Diagnosis  of  Chronic  or  Latent  Abscess  of  the  Brain. — The  diagnosis 
of  chronic  or  latent  abscess  of  the  brain  following  injury  is  characterised  by 
the  history  of  a  wound  or  fracture  of  the  skull  which  has  been  more  or  less 
infected.  The  brain  symptoms  which  followed  the  injury,  if  such  were  pres- 
ent, usually  disappear,  the  patient  feels  relatively  or  completely  well.  Such 
a  period  may  last  for  two  or  three  weeks  or  for  as  many  years.  The  symp- 
toms which  follow  this  period  may  come  on  gradually  or  suddenly.  They 
consist  of  pain  and  headache,  which  may  be  referred  to  the  original  wound 
or  scar.  Frequently  there  is  trigeminal  neuralgia  of  great  severity.  Accom- 
panying the  headache,  etc.,  there  is  fever  of  a  moderate  grade,  often  inter- 
mittent. The  patient  may  now  be  suddenly  seized  with  spasmodic  contrac- 
tions of  the  muscles,  of  a  local  or  general  character.  Sometimes  a  typical 
attack   of   epilepsy   will   occur;   this   may   be   repeated,   and   be   followed   by 


Fig.  152. —  Abscess  of  the  Cerebral.  Cortex  (Frontal) 
following  a  very  severe  burn  of  the  scalp  "which 
became  Infected  and  Ended  in  the  Production  of  a 
Fatal  Abscess  of  the  Brain.  The  vitality  of  the  skull 
was  seriously  impaired  by  the  original  burn.  There  were  no 
focal  symptoms.     (New  York  Hospital,  authors  collection.) 


THE   DISEASES    OF    THE   BRAIN  435 

an  attack  of  hemiplegia  and  death,  with  the  symptoms  of  an  ordinary 
apoplexy. 

"  In  cases  where  an  injury  of  the  head  is  followed  some  time  afterwards 
by  evening  rises  of  temperature,  by  headache,  convulsive  attacks,  and  paralyses 
upon  the  side  of  the  body  opposite  to  the  original  injury,  it  is  possible  that  an 
abscess  of  the  brain  exists  "  (v.  Bergmann). 

Abscess  of  the  Brain  Following  Middle-ear  Disease. — The  diagnosis 
depends  first  upon  the  presence  or  a  history  of  disease  of  the  ear;  further,  as 
has  been  stated  of  abscess  of  brain  elsewhere,  upon  symptoms  due  to  sepsis, 
to  paralyses,  or  symptoms  of  irritation  of  definite  portions  of  the  brain  (local- 
izing symptoms),  to  symptoms  of  cerebral  compression.  Fever  is  inconstant, 
rarely  marked,  often  intermittent.  A  daily  evening  rise  of  temperature,  with 
morning  remissions,  suggests  other  forms  of  intracranial  suppuration  rather 
than  abscess,  and  sharp  attacks  of  intermittent  fever  to  involvement  of  the 
mastoid  cells.  In  cases  of  abscess  the  patients  complain  of  loss  of  appetite, 
of  constipation,  of  weakness  and  lassitude,  notably  in  the  evening,  sometimes 
of  chilly  sensations.  Headache  is  fairly  constant,  and  is  made  worse  by 
percussion  upon  the  skull  over  the  affected  area ;  it  is  often  worse  in  the 
evening  or  when  fever  is  present.  Vomiting,  occurring  at  irregular  times 
irrespective  of  the  ingestion  of  food,  upon  exertion  or  upon  rising  from 
a  sitting  posture,  is  fairly  constant  and  characteristic.  The  pulse  is  usu- 
ally slow. 

Certain  mental  symptoms  are  present.  Cerebration  is  sluggish,  the 
patients  are  inattentive,  do  not  readily  comprehend  what  is  said  to  them,  and 
answer  questions  slowly  and  with  effort.  They  are  inclined  to  sleep  a  great 
deal,  and  are  irritable.  Examination  of  the  eyes  often  shows  choked  disk 
upon  the  affected  side.  Localizing  symptoms  may  be  absent.  Deafness  and 
facial  paralysis  may  be  present,  but  are  often  due  to  the  disease  of  the  ear 
itself  and  to  caries  of  the  petrous  portion  of  the  temporal  bone.  When  the 
disease  is  upon  the  left  side  and  the  abscess  is  in  the  temporal  region  of  the 
brain,  about  half  the  cases  will  be  affected  with  sensory  aphasia  more  or  less 
complete.  These  disturbances  of  speech  are  rarely  very  pronounced,  and  are 
often  transitory.  Those  abscesses  situated  in  the  temporal  lobe  of  the  brain 
frequently  give  no  pressure  symptoms  whatever,  and  often  no  localizing  symp- 
toms of  any  kind.  The  deafness,  the  facial  paralysis,  dilatation  of  the  pupil 
upon  the  affected  side,  are  believed,  in  the  majority  of  instances,  to  depend 
upon  the  disease  of  the  petrous  portion  of  the  temporal  bone,  or  upon  external 
pachymeningitis. 

The  abscesses  which  are  situated  in  the  cerebellum  give  even  fewer  local- 
izing symptoms  than  those  already  spoken  of.  They  are,  perhaps,  more  often 
combined  with  or  overshadowed  by  the  symptoms  of  meningitis,  pachymenin- 
gitis, sinus  thrombosis,  and  pyemia.  An  uncertain,  staggering  gait,  rigidity  of 
the  muscles  of  the  back  of  the  neck,  and  sometimes  giddiness,  point  to  the  loca- 
tion of  the  abscess  in  the  cerebellum.     The  methods  of  seeking  for  abscess 


436  INJUEIES   AND   DISEASES    OF   THE   BEAIN 

of  the  brain  and  of  opening  the  skull  belong  rather  to  the  domain  of  operative 
surgery. 

Abscesses  of  the  Brain  Secondary  to  Infectious  Processes  of  the  Nose 
and  the  Frontal  Sinus. — Abscesses  of  the  brain  secondary  to  infectious  proc- 
esses of  the  nose  and  the  frontal  sinus  seldom  give  any  localizing  symptoms, 
unless  they  are  of  such  large  size  as  to  reach  backward  to  the  motor  areas  or 
the  speech  center.  They  also  are  usually  combined  with  meningitis,  suppu- 
ration in  the  cavernous  sinus,  etc.  They  follow  disease  of  the  bones  and 
infected  fracture,  notably  gunshot  fractures  situated  in  the  forehead,  in  the 
orbit,  the  upper  jaw,  the  ethmoid  bone.  Chronically  suppurating  wounds 
and  fractures  involving  the  anterior  fossa  of  the  skull  may  give  rise  to  the 
suspicion  of  abscess  of  the  brain  when  the  patient  begins  to  lose  strength,  to 
suffer  from  headache,  to  feel  dull,  to  vomit  when  his  stomach  is  empty,  and 
to  have  chilly  sensations  in  the  evening. 

Differential  Diagnosis. — The  following  differential  diagnosis  between 
meningitis,  abscess  of  the  brain,  and  sinus  thrombosis  is  taken  from  Starr's 
"  Brain  Surgery,"  p.  190. 

In  meningitis  there  is  usually  a  more  rapid  onset  and  progress  of  the  symptoms 
than  in  brain  abscess.  In  meningitis  the  headache  is  associated  with  hyperesthesia 
to  sound  and  light  and  touch  all  over  the  body,  symptoms  usually  absent  in  cerebral 
abscess.  In  meningitis  the  temperature  is  high  and  the  pulse  is  rapid,  irregular, 
and  intermittent.  In  meningitis  there  are  occasional  spasms  and  convulsions ; 
strabismus  appears  and  trismus  is  common;  and  pain  and  rigidity  along  the  neck 
are  complained  of  as  the  disease  advances.  Thus  there  are  numerous  points  which 
distinguish  the  two  diseases  from  one  another.  Sinus  thrombosis  has  also  numer- 
ous points  of  differentiation  from  cerebral  abscess.  High  fever  with  pyemic  varia- 
tions in  its  range  and  frequent  chills;  a  very  rapid  pulse,  swelling  and  edema  over 
the  mastoid  process  and  edema  of  the  neck,  swelling  along  the  jugular  vein,  which 
stands  out  like  a  hard  cord  in  the  neck,  exophthalmos  and  even  swelling  of  the  con- 
junctiva, and  marked  venous  stasis  in  the  vessels  of  the  scalp,  are  all  symptoms  not 
observed  in  cerebral  abscess,  but  characteristic  of  sinus  thrombosis.  Choked  disk 
appears  early  in  the  course  of  the  case,  while  it  is  often  wanting  in  cerebral  abscess. 

Tumors  of  the  Brain. — A  small  proportion  only  of  tumors  of  the  brain 
cause  symptoms  such  that  they  can  be  accurately  localized,  and  a  still  smaller 
proportion  afford  a  favorable  field  for  surgical  interference.  Starr  estimates 
that  not  more  than  seven  per  cent  of  all  brain  tumors  can  be  operated  upon 
with  a  prospect  of  success.  It  is,  of  course,  of  the  utmost  importance  that 
the  diagnosis  be  made  at  the  earliest  possible  moment  if  an  operation  is  to 
be  undertaken.  Sarcoma,  glioma,  gliosarcoma,  and  fibroma  are  the  com- 
monest forms  of  tumor  which  occur  primarily  in  the  brain.  Carcinoma  of 
the  brain  is  secondary  to  carcinoma  elsewhere  in  nearly  all  cases.  Gummata, 
tubercular  infiltration,  and  echinococcus  cysts  are  usually  grouped  with  brain 
tumors  because  they  cause  similar  symptoms.  In  America,  echinococcus  is 
much  less  common  than  on  the  Continent  of  Europe. 


THE   DISEASES    OF   THE   BRAIN 


437 


The  accompanying  photograph  is  of  the  brain  of  a  man  who  was  admitted 
to  the  Hudson  Street  Hospital,  delirious  and  suffering  from  rapidly  repeated 
general  convulsions.  There  were  no  localizing  symptoms.  He  died  within 
twenty-four  hours  after  admission,  and  the  autopsy  disclosed  the  cyst  as  seen  in 
the  picture.  No  previous 
history  of  the  case  could  be 
obtained.  The  patient  was 
a  Greek.  The  diagnosis  of 
echinococcus  cyst  was  made 
from  the  pathological  exam- 
ination of  the  tumor.  Tu- 
mors of  the  brain  occur  both 
in  children  and  adults  with 
nearly  equal  frequency. 

Sarcoma  is  the  most  fre- 
quent form  in  adults,  tuber- 
culous disease  in  children. 
Gumma  is  common  in  adults, 
but  usually  yields  to  specific 
treatment.  Only  a  moderate 
number  of  brain  tumors  can 
be  located  by  the  symptoms. 
In  some  parts  of  the  brain 
tumors  produce  no  localiz- 
ing symptoms,  and  in  others 
localizing  symptoms  occur, 
but  diagnostic  errors  are 
possible  because  tumors  of  the  cortex  or  in  the  region  of  the  basal  ganglia  may 
produce  quite  similar  disturbances.  In  all  cases  of  suspected  brain  tumor,  syph- 
ilis must  be  sought  for,  and  if  the  history  is  doubtful,  active  treatment  for  a 
number  of  weeks  should  be  employed.  In  children  especially,  evidences  of  tu- 
berculosis elsewhere  point  to  a  probability  that  the  brain  trouble  is  of  the  same 
character.  In  cases  of  metastatic  carcinoma  of  the  brain  the  primary  tumor  or 
the  scar  left  after  its  removal  will  be  evident.  The  sarcomata  very  rarely  occur 
as  secondary  tumors  in  the  brain.  The  parasitic  cysts  of  the  brain  are  of 
slower  growth  than  the  other  forms  of  brain  tumor,  and  very  seldom  give  rise 
to  any  localizing  symptoms,  because  they  do  not  destroy  the  brain  nor  infiltrate 
it,  but  simply  displace  it.  The  symptoms,  therefore,  in  these  cases,  will  be 
general  rather  than  local.  In  a  certain  proportion  of  cases  of  sarcoma  and 
glioma  there  will  be  a  history  of  injury  to  the  head.  In  those  cases  of  brain 
tumor  which  show  marked  variation  in  the  intensity  of  the  symptoms  made 
under  different  conditions  of  circulatory  activity  and  changes  in  the  blood 
pressure,  there  is  a  probability  that  the  tumor  is  of  a  vascular  character — a 
vascular  sarcoma  or  glioma. 


Fig.  153. — Echinococcus  Cyst  of  the  Brain.  The  speci- 
men was  obtained  at  autopsy  in  the  House  of  Relief  of  the 
New  York  Hospital.  The  patient  was  brought  to  the  hos- 
pital the  evening  before  his  death.  He  was  stupid  and 
soon  began  to  suffer  from  general  convulsions.  In  a  few 
hours  the  stupor  was  followed  by  coma  and  the  next  day 
he  died.  The  cyst  of  the  brain  was,  of  course,  unsuspected 
until  its  presence  was  revealed  upon  opening  the  skull. 


438  INJURIES   AND   DISEASES    OF   THE   BRAIN 

Tumors  may  develop  in  any  portion  of  the  brain,  and  many  of  them, 
although  easy  to  diagnosticate,  are  so  situated  as  to  be  entirely  beyond  the 
reach  of  surgical  interference.  They  are  those,  especially,  which  develop  in 
the  basal  portion  of  the  braiu — the  pons,  the  medulla,  the  several  basal 
ganglia.  They  produce  fairly  definite  symptoms,  referable  particularly  to  the 
functions  of  the  cranial  nerves.  A  considerable  proportion  of  cerebral  tumors, 
notably  in  children,  develop  in  the  cerebellum.  The  following  group  of  symp- 
toms are  often  present: 

There  will  be  general  symptoms  of  disturbance  of  the  brain — headache, 
vomiting,  a  change  in  the  mental  disposition,  apathy  or  irritability,  sometimes 
vertigo,  the  signs  of  optic  neuritis,  sometimes  blindness,  more  rarely  general 
convulsions.  The  headache  may  be  referred  to  the  back  part  of  the  head, 
or  it  may  be  a  general  headache,  or  be  referred  to  the  frontal  region.  Tender- 
ness on  percussion  over  the  back  part  of  the  skull  is  present  in  many  cases. 
The  local  symptoms  of  cerebellar  tumor  are  giddiness  and  a  staggering  gait 
in  walking.  The  staggering  may  occur  away  from  or  toward  the  affected 
side  of  the  brain;  the  symptom  indicates  that  the  middle  lobe  of  the  cere- 
bellum is  involved.  If  symptoms  of  compression  of  one  or  more  of  the  cranial 
nerves  is  present,  it  is  probable  that  the  site  of  the  tumor  corresponds  with 
the  side  upon  which  the  nerves  are  paralyzed.  The  tumors  of  the  brain  most 
accessible  to  operation,  and  whose  exact  location  is  most  readily  made  out, 
are  those  situated  in,  or  beneath,  the  cortex  of  the  brain,  in  or  near  the  motor 
areas.  The  symptoms  produced  by  these  tumors  are  general  and  local.  The 
general  symptoms  consist,  as  in  other  brain  tumors,  of  headache,  vomiting, 
sometimes  of  changes  in  cerebration,  choked  disk. 

The  local  symptoms  consist  sometimes  of  tenderness  on  percussion  over 
the  site  of  the  tumor,  sometimes  in  a  local  elevation  of  temperature  in  the 
same  region.  There  are  quite  regularly  localized  muscular  spasms  of  certain 
groups  of  muscles.  The  spasms  are  sometimes  preceded,  as  in  Jacksonian 
epilepsy,  by  subjective  sensations  of  heat,  cold,  numbness,  tingling,  etc.  At 
first  these  spasms  occur  in  only  one  muscle,  or  in  a  limited  group  of  muscles; 
the  patient  has  a  twitching  of  one  eyelid,  of  the  corner  of  the  mouth,  of  a 
toe  or  finger.  As  the  tumor  grows  larger  and  invades  new  portions  of  the 
brain,  spasms  of  other  groups  of  muscles  will  follow  in  regular  order,  until 
they  may  involve  the  muscles  of  the  entire  half  of  the  body.  During  the 
occurrence  of  the  convulsive  movements,  consciousness  is  not  interfered  with 
unless  the  tumor  has  reached  a  very  considerable  size.  After  the  spasms  have 
recurred  for  a  certain  length  of  time,  the  muscles  become  gradually  or  sud- 
denly paralyzed,  and  subsequently  contracted.  When  tumors  develop  in  the 
occipital  region  they  will  be  accompanied  by  hemianopsia;  when  they  involve 
the  sensory  area  in  the  parietal  region,  as  well  as  the  motor  area,  there  will 
be  sensory  as  well  as  motor  disturbances.  If  they  are  upon  the  left  side 
they  may  produce  sensory  aphasia  or  word  blindness,  or  in  the  temporal 
lobe   word    deafness    (Starr).      It   is,    of   course,    impossible   to    discuss    here 


TILE    DISEASES    OF    THE    BKAIN  439 

at  length  the  various  localizing  symptoms  "which  may  occur  in  tumors  of 
the  brain. 

Epilepsy. — Jacksonian  epilepsy  is  caused  by  some  focus  of  irritation  in  the 
motor  area  of  the  brain.  The  attacks  begin  with  a  sensation  of  heat,  cold, 
tingling,  or  numbness  in  some  particular  part  of  the  body,  followed  by  spas- 
modic muscular  contractions  in  the  same  area;  thence  the  sensations  and  con- 
tractions spread  in  a  definite  order  to  other  groups  of  muscles,  and  are  fol- 
lowed by  fatigue  and  weakness  of  these  muscles.  There  may  be  partial  loss 
of  sensation  lasting  for  several  hours  in  the  same  regions  as  showed  the 
spasms.  The  patient  may  lose  consciousness  if  the  spasms  end  in  a  general 
convulsion.  A  sensory  equivalent  of  the  spasms  may  occur  when  other  areas 
of  the  brain  are  irritated.  Thus  sights,  sounds,  smells,  or  tastes  may  be  per- 
ceived at  the  beginning  of  the  attack,  indicating  irritation  of  the  occipital 
region,  or  of  the  temporal  region,  or  of  the  temporo-sphenoidal  region,  respec- 
tively. Sometimes  the  attacks  begin  with  a  spasm  of  the  muscles  of  the  right 
side  of  the  face,  and  are  accompanied  or  followed  by  motor  aphasia.  In  these 
cases  the  irritation  is  situated  in  the  third  frontal  convolution  upon  the  left 
side  of  the  brain.  There  are  also  psychical  attacks  attended  by  mania  or 
stupor  which  are  the  equivalent  of  the  other  forms,  the  irritative  lesion  being 
situated  in  the  frontal  lobes  of  the  brain. 

Very  varied  lesions  of  the  brain  may  cause  epilepsy — sometimes  of  the 
ordinary  idiopathic  type,  with  general  convulsions  and  unconsciousness,  some- 
times of  the  Jacksonian  type  just  described:  Thus,  fractures  of  the  skull,  with 
depression  or  splintering,  and  the  lodgment  of  fragments  of  the  inner  table  in 
the  brain;  inflammation  of  the  dura,  of  any  origin — syphilitic,  tubercular,  or 
traumatic,  the  presence  of  a  tumor  in  the  motor  area  of  the  cortex;  small 
hemorrhages  into  the  cortex;  small  areas  of  sclerosis  or  of  softening,  and  other 
lesions.  When  Jacksonian  epilepsy  follows  injury,  the  site  of  the  wound  or 
fracture,  with  or  without  depression,  may  correspond  with  the  localizing  symp- 
toms or  it  may  not.  If  the  site  of  the  injury  and  the  localizing  symptoms 
correspond,  the  point  at  which  the  skull  should  be  opened  to  reach  the  source 
of  irritation  is  evident.  If  they  do  not,  Starr  believes,  from  conclusions  based 
upon  experience,  that  the  localizing  symptoms  are  a  better  guide  to  operation 
than  the  site  of  the  injury.  If  the  brain  is  exposed  and  no  lesion  is  found, 
the  area  whence  the  irritation  is  supposed  to  proceed  may  be  identified  bv 
touching  various  points  of  the  cerebral  surface  with  delicate  electrodes  bearing 
a  mild  Faradic  current,  until  the  muscles  in  which  the  spasms  begin  during 
an  attack  are  caused  to  contract. 

Hydrocephalus. — An  accumulation  of  watery  fluid  in  the  interior  of  the 
skull  may  occur,  very  rarely,  between  the  brain  and  its  membranes;  that  is, 
between  the  dura  and  the  brain.  When  congenital,  and  due  to  imperfect  de- 
velopment of  the  brain,  the  children  do  not  long  survive.  In  the  acquired 
form  the  condition  may  occur  in  children  and  in  adults  from  atrophv  of  the 
brain,  as  a  rare  condition  following  wasting  diseases.     Localized  accumulations 


440  INJURIES   AND   DISEASES    OF    THE   BRAIN 

of  serous  fluid  may  occur  in  adults  beneath  the  dura,  as  the  result  of  chronic 
inflammation.  Hydrocephalus  of  the  ventricles  of  the  brain  is  a  common  dis- 
ease, and  either  congenital  or  acquired.  The  acquired  form  is  usually  devel- 
oped during  the  early  years  of  life;  the  congenital  form  is  usually  due  to 
imperfect  development  of  the  brain.  The  watery  fluid  occupies  chiefly  the 
lateral  ventricles.  In  the  acquired  form  the  condition  may  be  due  to  inflam- 
mation, usually  tubercular,  of  the  lining  of  the  ventricles,  or  to  interference 
with  the  venous  circulation  in  the  veins  of  Galen  by  a  tumor  or  other  cause. 

The  diagnosis  of  congenital  hydrocephalus  is  to  be  made  by  observing  an 
abnormal  increase  in  the  size  of  the  head,  by  unusual  size  of  the  fontanelles, 
and  the  imperfect  union  of  the  sutures  of  the  skull.  The  development  of  the 
intelligence  of  these  children  is  slow  or  imperfect.  They  learn  to  speak  with 
difficulty,  or  not  at  all.  The  contrast  between  the  enlarged  and  overhanging 
skull  and  the  small  face  is  very  striking.  Blindness  and  various  mental  symp- 
toms develop  during  the  course  of  the  disease.  When  hydrocephalus  develops 
after  the  skull  has  become  ossified,  the  enlargement  of  the  head  is  wanting 
and  the  symptoms  are  rather  those  of  a  tumor  of  the  brain — headache,  blind- 
ness, vomiting,  squint,  mental  dullness,  etc.  Congenital  hydrocephalus  fre- 
quently accompanies  rachitis. 

Hernia  cerebri — Cephalocele. — Prolapse  of  the  brain  following  traumatisms 
has  already  been  spoken  of.  The  congenital  forms  occur  as  the  result  of  im- 
perfect development  of  the  skull,  such  that  the  bony  covering  of  the  brain  is 
wanting  in  certain  situations,  and  through  these  gaps  portions  of  the  contents 
of  the  cranium  protrude.  These  hernia?  occur  in  the  occipital  region;  at  the 
root  of  the  nose ;  rarely  in  the  parietal  region  and  in  the  region  of  the  large 
fontanelle.  Still  more  rarely  they  may  occur  in  the  base  of  the  skull,  and 
protrude  into  the  cavity  of  the  nose  or  into  the  throat,  or  even  through  a  cleft 
palate  into  the  mouth,  or  through  the  orbital  fissure  into  the  orbit,  or  into  the 
spheno-maxillary  fossa.  They  may  contain  the  membranes  of  the  brain  merely 
(meningocele),  or  the  brain  and  its  membranes  (encephalocele),  or  the  brain 
and  its  membranes  inclosing  a  cavity  dilated  into  a  sac  filled  with  fluid  com- 
municating with  one  of  the  lateral  ventricles  of  the  brain  (hydrencephalocele). 

Many  of  these  congenital  hernia?  are  associated  with  a  high  grade  of  de- 
formity of  skull  and  imperfect  development  of  the  brain.  The  children  are 
often  born  dead,  or  die  soon  after  birth.  This  is  particularly  true  of  the  cases 
of  hydrencephalocele.  Those  who  survive  for  any  length  of  time  are  idiots, 
or  more  or  less  imbecile  or  feeble-minded.  The  hernia?  vary  much  in  size  and 
shape ;  they  may  be  very  small  and  hardly  noticeable,  or  as  large  as  a  child's 
head  and  sessile  or  pedunculated.  The  tumor  may  form  a  single  rounded  or 
ovoid  mass,  or  be  more  or  less  lobulated  or  divided  into  several  partly  separate 
sacs.  The  tumors  are  usually  compressible ;  if  they  contain  much  fluid  they 
are  translucent ;  they  may  show  cerebral  pulsation.  Firm  pressure  upon  the 
tumor  causes  it  to  diminish  in  size,  sometimes  with  the  production  of  cerebral 
symptoms — slowing  of  the  pulse,  vomiting,  muscular  spasms — occasionally  nn- 


THE   DISEASES    OF   THE   BRAIN 


441 


consciousness.  It  is  sometimes  possible  to  feel  the  border  of  the  orifice  in  the 
skull  after  the  tumor  has  been  partly  reduced.  When  the  patient  cries  or 
coughs  the  sac  is  increased  in  size ;  during  sleep  it  becomes  smaller. 

Varieties  of  Hernia  cerebri. — The  meningoceles  occur  most  often  in 
the  occipital  region,  and  protrude  below  or  above  the  tentorium  cerebelli.     They 


Fig.  154. — Meningocele.  The  infant  shown  in  Figs.  154  and  155  was  a  patient  in  the  service  of  Dr. 
Lewis  A.  Stimson  in  the  New  York  Hospital.  The  large  translucent  tumor  was  connected  with  the 
interior  of  the  skull  but  did  not  appear  to  contain  any  brain  tissue.  When  pressed  upon  slight 
symptoms  of  compression  of  the  brain  could  be  produced.     The  child  did  not  long  survive. 

sometimes  occur  upon  the  front  of  the  head.  The  brain  may  be  normal  or  the 
condition  may  be  associated  with  hydrocephalus  and  imperfect  development  of 
the  brain  and  an  abnormally  small  skull — microcephalics.     The  children  may 


Fig.  155. — Meningocele. 


be  idiots;  a  good  many  of  them  die  soon  after  birth  or  during  infancy;  occa- 
sionally they  live  to  grow  up.  The  meningoceles  usually  form  smooth  tumors 
covered  by  thinned  integument.  They  are  translucent ;  they  fluctuate ;  they 
may  be  quite  tense  or  only  partly  filled  with  fluid.     They  may  be  entirely  re- 


442  INJURIES   AND   DISEASES    OF   THE   BRAIN 

ducible;  they  seldom  pulsate.  Symptoms  of  cerebral  compression  may  occur 
from  pressure  upon  the  tumor,  as  already  noted. 

The  encephaloceles  are  more  common  than  meningoceles ;  they  contain  a 
certain  amount  of  brain  substance,  which  is  connected  by  a  pedicle  with  the 
brain  inside  the  skull.  They  may  be  solid,  or  contain  a  cavity  which  communi- 
cates through  a  canal  with  the  lateral  ventricle — hydrencephalocele.  The  en- 
cephaloceles occur  more  often  in  the  front  part  of  the  skull  than  in  the  occipital 
region.  They  form  tumors  of  small  or  moderate  size ;  they  pulsate  more  mark- 
edly, as  a  rule,  than  do  the  meningoceles,  and  show  similar  signs  and  symp- 
toms when  compressed.  They  increase  in  size  during  crying  and  coughing, 
and  diminish  in  size  during  sleep.  If  the  dural  sac  contains  much  fluid,  they 
will  be  translucent.  When  a  considerable  portion  of  the  brain  lies  external  to 
the  skull,  the  children  are  usually  born  dead  or  die  soon  after  birth.  If  they 
survive  for  any  length  of  time  they  are  usually  idiots ;  the  skull  remains  small 
and  undeveloped.  If  but  a  small  protrusion  is  present  the  children  may  sur- 
vive, and  may  even  grow  up  to  be  persons  of  at  least  partly  normal  development. 

Diagnosis. — In  the  diagnosis  of  these  conditions  the  main  points  are  that 
they  are  congenital  tumors,  plainly  communicating  with  the  interior  of  the 
skull,  as  described,  and  often  associated  with  microcephalus.  Those  in  the 
occipital  region  are  usually  meningoceles.  Those  containing  brain  substance 
are  more  often  found  at  the  root  of  the  nose  than  in  the  occipital  region.  The 
hydrencephaloceles  are  more  common  than  meningoceles,  and  occur  also  chiefly 
in  the  occipital  region.  They  are  generally  rather  large  tumors ;  they  fluctuate, 
are  often  translucent;  they  are  not  reducible,  but  diminish  somewhat  in  size 
upon  pressure.  The  skull,  in  most  instances,  is  otherwise  deformed.  The 
encephaloceles  are  usually  small  tumors,  and  may  be  even  met  with  in  adult 
life.  They  are  commonly  situated  in  the  front  of  the  skull ;  they  are  not 
completely  reducible;  they  pulsate,  and  increase  in  size  on  coughing,  etc.,  and 
diminish  during  sleep. 

By  viewing  the  hernia  by  transmitted  light  it  may  be  possible  to  see  less 
translucent  portions  representing  brain  tissue.  An  X-ray  picture  may  some- 
times show  the  extent  of  the  orifice  in  the  skull.  The  greater  the  proportion 
of  the  brain  lying  outside  the  skull  the  less  these  cases  are  suitable  for  opera- 
tion. The  meningoceles  with  a  narrow  pedicle  are  most  favorable.  When 
associated  with  microcephalus,  hydrocephalus,  idiocy,  or  combined  with  defects 
in  the  cervical  vertebra?,  etc.,  they  are  better  let  alone. 

INJURIES    AND    DISEASES    OF    THE    FRONTAL    SINUS 

Injuries  of  the  Frontal  Sinus. — Wounds  of  the  forehead,  associated  with 
fractures  of  the  anterior  wall  of  the  frontal  sinus  by  direct  violence,  are  open 
to  inspection  and  present  no  difficulties  of  diagnosis.  Subcutaneous  fractures, 
associated  with  laceration  of  the  mucous  membrane  lining  the  sinus,  are  usually 
followed  by  subcutaneous  emphysema  of  the  forehead  and  eyelids,  recognizable 


INJURIES    AND   DISEASES    OE   THE   FRONTAL   SINUS  443 

by  crackling  and  palpation.  The  emphysema  is  increased  by  sneezing,  and 
by  expiratory  efforts  when  the  mouth  and  nose  are  closed.  Pain  and  local 
tenderness  are  present,  and  depression  may  be  recognizable  on  palpation. 

Acute  Catarrhal  Inflammation  of  the  Frontal  Sinus. — Acute  catarrhal  inflam- 
mation of  the  frontal  sinus,  complicating  acute  coryza,  causes  frontal  headache, 
sometimes  tenderness  over  the  sinus. 

Mechanical  Closure  of  the  Outlet  to  the  Nose. — As  the  result  of  chronic  in- 
flammation, a  hematoma,  or  the  growth  of  tumors,  the  outlet  from  the  sinus 
may  be  plugged,  and  the  accumulated  serous,  mucous,  or  purulent  exudate 
may  cause  gradually  dilatation  of  the  sinus  wall,  generally  in  the  direction  of 
the  orbit.     The  eye  may  thus  be  displaced  downward  and  outward. 

Empyema  of  the  Frontal  Sinus. — Empyema  of  the  frontal  sinus  occurs  as 
an  extension  from  inflammations  of  the  mucous  membrane  of  the  nose ;  from 
infected  fractures  of  its  wall;  from  septic,  tubercular,  or  syphilitic  diseases 
of  bone ;  from  the  growth  of  tumors ;  the  presence  of  foreign  bodies,  and  of 
the  larvae  of  insects.  The  inflammation  may  be  acute  or  chronic.  The  symp- 
toms of  acute  purulent  inflammation  are  fever,  local  pain  (often  referred  to 
the  distribution  of  the  supra-orbital  nerve),  tenderness  and  swelling  of  the 
forehead,  and  a  purulent  discharge  from  the  nose.  If  the  outlet  through  the 
infundibulum  to  the  nose  is  plugged,  the  pain  will  be  more  severe.  The  ob- 
struction may  be  overcome  from  time  to  time  with  the  escape  of  a  quantity 
of  pus  from  the  nose  on  sneezing  and  coughing.  The  wall  of  the  sinus  may 
gradually  be  dilated,  producing  deformity,  or  perforation  may  take  place  into 
the  nose,  the  orbit,  the  forehead,  or  into  the  interior  of  the  skull,  with  fatal 
meningitis.  Rupture  into  the  orbit  is  followed  by  a  retrobulbar  abscess  or 
phlegmon,  with  exophthalmos,  double  vision,  ptosis,  blindness.  Softening  and 
perforation  of  the  anterior  wall  of  the  sinus  may  lead  to  an  abscess,  or  to 
pneumatocele  capitis,  as  already  described.  In  acute  cases,  perforation  ante- 
riorly will  be  accompanied  by  pain,  tenderness,  redness,  and  edema  of  the 
forehead  and  eyelids,  and  severe  frontal  headache.  The  septic  symptoms  will, 
of  course,  vary  much  in  intensity  in  different  cases. 

Tumors  of  the  Frontal  Sinus. — The  several  forms  of  polypi — mucous,  fibrous, 
and  mucous  cysts — occur  in  the  frontal  sinus,  sometimes  associated  with  similar 
growths  in  the  nose.  If  they  close  the  infundibulum  they  will  produce  the 
symptoms  of  catarrh  of  the  sinus,  sometimes  with  dilatation,  as  described. 
Osteoma  is  the  most  frequent  tumor.  It  is  of  slow  growth,  and  causes  in 
time  symptoms  of  irritation  or  of  catarrh,  frontal  headache  or  neuralgia,  the 
signs  of  acute  inflammation  being  absent ;  later,  distention  and  deformity.  As 
already  stated,  these  tumors  originate  as  cartilaginous  tumors  in  the  ethmoid 
bone,  and  grow  into  the  frontal  sinus  or  the  nose  or  into  the  orbit.  These 
tumors  may  sometimes  grow  to  a  large  size,  causing  deformities,  notably  dis- 
placement of  the  eyeball  and  interference  with  vision.  Supra-orbital  neural- 
gias, of  greater  or  less  severity,  may  occur  from  pressure.  If  they  grow  into 
the  anterior  fossa  of  the  skull  they  may  rarely  produce  pressure  symptoms. 


444  INJURIES   AND   DISEASES    OF   THE   BRAIN 

The  pedicle  of  these  osteomata  may  undergo  atrophy  or  fracture,  and  they 
then  exist  as  foreign  bodies.  These  bony  tumors  are  to  be  recognized  by  their 
slow  growth  and  bony  hardness.  When  exposed  in  the  cavity  of  the  sinus  they 
are  covered  with  mucous  membrane,  and  thus  resemble  a  polypus  in  appear- 
ance. Carcinoma  may  occasionally  arise  from  the  wall  of  the  frontal  sinus1, 
in  mode  of  growth  and  destructiveness  it  does  not  differ  from  carcinoma  else- 
where. 


CHAPTER    XV 


INJURIES  AND   DISEASES  OF  THE  FACE 


CONGENITAL    DEFECTS 


Harelip. — The  deformity  of  harelip  is  so  well  known  as  to  need  no  descrip- 
tion. I  will  merely  enumerate  the  different  forms  and  grades  of  the  condi- 
tion. The  cleft  in  the  lip  lies  to  one  side  of  the  median  line :  it  may  be  single 
or  double,  and  varies  in  extent  from  a  slight  furrow  to  a  cleft  running  up  to 
and  through  the  nostril,  involving  the  alveolar  border  of  the  jaw,  when  it  is 
often  combined  with  median  fissure 
of  the  hard  palate,  or  of  the  soft 


palate  as  well.  In  double  harelip, 
intermaxillary  bones  form  a  more 
or  less  prominent  projection  at- 
tached to  the  vomer,  and  frequent- 
ly are  tilted  upward  and  forward 
beneath  the  nose. 


Fig.  156. — Double  Harelip  in  an  Infant. 
(Roosevelt  Hospital,  collection  of  Dr. 
Charles  McBurney.) 


Fig.  157. — Single  Harelip  in  an  Adult.  (Roose- 
velt Hospital,  collection  of  Dr.  Charles  McBur- 
ney.) 


Cleft  Palate. — The  fissures  of  the  hard  palate  occur  alone,  or  with  harelip 

and  fissures  of  the  alveolar  border.     In  cases  of  double  cleft  palate  the  vomer 

445 


446 


INJUKIES   AND   DISEASES    OF   THE   FACE 


remains  ununited  to  the  palate,  and  presents  as  a  central  diaphragm  when 
viewed  from  the  mouth.  Central  fissures  of  the  soft  palate  occur  alone,  or 
combined  with  fissures  of  the  hard  palate.  In  some  cases  of  harelip  and  cleft 
palate  the  intermaxillary  bones  are  not  developed,  and  a  broad  space  is  thus 
left  beneath  the  nose.  Such  deformities  are  sometimes  associated  with  imper- 
fect development  of  the  brain. 

Rare  Congenital  Defects. — Other  rarer  forms  of  congenital  defects  are  com- 
plete or  partial  median  cleft  of  the  lower  lip,  sometimes  combined  with  a  fur- 
row between  each  nostril  and 
the  bridge  of  the  nose.  This 
is  the  so-called  "  dog-nose  "  de- 
formity. There  are  also  cases 
of  median  fissure  of  the  nose, 
and  of  congenital  absence  of 
the  nose ;  of  congenital  fistula 
in  the  center  of  the  upper  lip ; 
of  lateral  fissures  of  the  upper 
lip  running  up  toward  the  eye 
— or  even  upon  the  forehead ; 
such  fissures  may  be  bilateral. 
Unilateral  or  bilateral  fissures 
running  outward  from  the  cor- 
ners of  the  mouth  have  been 
observed,  producing  "  macros- 
toma."  The  mouth  may  also 
be  abnormally  small.  Fissures 
of  the  lower  lip  are  very  rare; 
a  few  cases  have  been  reported. 
The  fissures  may  involve  the  median  line  of  the  lip  only,  or  include  the 
lower  jaw,  or  the  tongue  as  well — so  that  the  cleft  extends  nearly,  or  quite, 
to  the  hyoid  bone.  There  are  also  unilateral  or  bilateral  incomplete  fistula?  of 
the  lower  lip. 

A  variety  of  congenital  abnormalities  have  been  observed  of  the  external  ear. 
The  ear  may  be  unduly  large,  or  small,  or  absent.  The  external  auditory  canal 
may  be  closed  or  absent.  Congenital  auricular  appendages  occur  as  small 
fleshy  nodular  growths,  sometimes  containing  cartilage,  usually  in  front  of 
the  tragus.  Congenital  absence  of  the  tongue  has  been  observed.  The  congen- 
ital deformities  of  the  lower  jaw  are  several ;  the  jaw  may  be  too  small,  one  side 
may  be  larger  than  the  other,  or  the  jaw  may  be  double.  The  entire  half  of 
the  face  may  be  notably  smaller  on  one  side  than  the  other.  Hypertrophy  of 
one  half  of  the  face  is  much  less  common. 


Fig.  158. — Harelip  and  Cleft  Palate  in  an  Adult. 
(Roosevelt  Hospital,  collection  of  Dr.  Charles  McBur- 
ney.) 


INJURIES    OF   THE   FACE  447 

INJURIES    OF    THE    FACE 

Contusions  of  the  face  are  followed,  where  the  tissues  are  loose,  notably 
in  the  eyelids,  by  the  well-known  ecchymotic  discoloration  "  black  eye."  Con- 
tused wounds  made  against  sharp  bony  prominences,  such  as  the  edge  of  the 
orbit,  may  resemble  incised  wounds  more  or  less  closely. 

Wounds  of  branches  of  the  fifth  pair  of  cranial  nerves  are  not  commonly 
followed  by  permanent  paralysis  of  sensation;  complete  or  partial  union  and 
regeneration  is  the  rule.  A  painful  neurofibroma  may,  very  rarely,  form  upon 
the  cut  end  of  the  nerve.  The  nerve  may  be  included  in  a  scar  and  cause 
neuralgia.     (See  also  Injuries  of  Nerves.) 

Division  of  the  levator  palpebral  muscle  within  the  orbit  may  be  followed  by 
retraction  of  the  muscle  and  permanent  ptosis — unless  sutured.  Severe  incised 
as  well  as  contused  and  lacerated  wounds  of  the  face,  if  infected,  are  occasion- 
ally followed  by  secondary  hemorrhage.  I  once  saw  a  nearly  fatal  secondary 
hemorrhage  from  the  facial  artery  in  an  infected  incised  wound  of  the  cheek. 

Gunshot  Wounds  of  the  Face. — Gunshot  wounds  of  the  face  are  nearly 
always  accompanied  by  injuries  of  the  bone.  Great  destruction  of  the  bones 
and  soft  parts  are  produced  by  shotgun  wounds  at  close  range,  and,  in  time  of 
war,  by  large  projectiles  or  portions  of  exploded  shells ;  also  by  dynamite  and 
other  explosions.  Small  shot,  spent  bullets,  and  bullets  from  small  pistols 
may  fail  to  penetrate  the  bone,  and  flatten  against  it.  Suicides  who  place  the 
muzzle  of  a  pistol  in  the  mouth  and  close  the  lips  upon  it  suffer  injuries  in 
which  an  explosive  action  is  marked.  The  soft  parts  are  burned ;  linear  tears 
may  proceed  in  a  radiating  manner  from  the  mouth,  through  the  lips  and 
cheeks ;  and  these  tears  have  often  clean-cut  edges.  The  injuries  are  fatal,  as 
a  rule,  when  the  shot  penetrates  the  base  of  the  skull  and  the  brain.  If  the 
pistol  is  pointed  too  far  forward,  because  the  individual  bends  his  head  too 
far  backward,  the  bullet  may  emerge  at  the  root  of  the  nose.  A  similar  experi- 
ment with  a  high-powered  rifle  literally  blows  the  top  of  the  head  off. 

The  gunshot  wounds  of  the  mouth  and  face  are  attended  by  three  dangers, 
especially  (injuries  of  the  brain  excepted)  :  they  are  hemorrhage,  from  the 
wounding  of  large  vessels  ;  asphyxia  ;  aspiration-pneunionia.  The  asphyxia  may 
be  caused,  immediately,  by  blood  flowing  into  the  trachea ;  by  paralysis  of  the 
tongue,  such  that  it  falls  back  and  closes  the  larynx,  when  the  muscles  which 
hold  it  forward  are  destroyed,  or  subsequently,  by  inflammatory  swelling,  caus- 
ing mechanical  closure  of  the  throat  or  edema  of  the  glottis.  The  danger  of 
asphyxia  immediately  after  the  injury  will  produce  very  definite  symptoms, 
and  a  suspicion  that  asphyxia  is  threatened  may  be  entertained  when  the  patient 
begins  to  complain  of  difficulty  in  swallowing  or  in  breathing. 

Wounds  of  the  Face. — Wounds  of  the  face  are  frequent  injuries — incised, 
contused,  and  gunshot  wounds,  all  are  common.  They  bleed  freely.  Division 
of  the  facial  or  of  the  temporal  artery,  superficial  or  deep,  may  be  followed 
by  fatal  bleeding.     The  facial  nerve,  Steno's  duct,  the  eyeball,  the  tear  duct, 


448 


INJURIES   AND   DISEASES    OE   THE   EACE 


may  be  wounded.  The  anatomical  situation  of  the  wound  aud  the  accompany- 
ing symptoms — bleeding,  facial  paralysis,  a  salivary  fistula,  or  the  escape  of 
saliva  from  the  wound,  disturbances  of  vision,  etc. — suffice  for  the  diagnosis. 
A  divided  tear  duct  usually  heals  without  trouble.  In  gunshot  and  stab  or 
punctured  wounds  of  the  face,  the  various  bony  cavities,  including  the  brain, 
may  be  wounded,  and  the  bullet,  or  a  portion  of  the  vulnerating  instrument, 
may  remain  in  the  wound.  Such  foreign  bodies  may  heal  in  the  wound  or 
cause  suppuration — if  in  the  brain,  usually  with  fatal  results.  Their  locality, 
if  of  metal,  can  usually  be  detected  with  the  X-rays.  The  vitality  and  blood 
supply  of  the  face  is  so  great  that  wounds  of  this  region  heal  quickly  and  well — 
better,  in  fact,  than  in  any  other  region.  Even  extensive  contused  and  lacer- 
ated wounds,  if  carefully  cleaned,  heal  with  very  little  trouble.  Powder  stains 
upon  the  face  are  common  after  self-inflicted  gunshot  wounds.     The  grains  of 

.  black  powder  embedded  in  the 
skin  remain  as  permanent  blue 
stains.  Smokeless  powder  leaves 
no  such  stain.  (See  Gunshot 
Wounds,  General  Surgery.) 

Tetanus.  —  Tetanus  may 
follow  wounds  of  the  face. 
(See  Tetanus.) 

Burning  of  the  Face. — Burn- 
ing of  the  face  occurs  from  hot 
fluids,  from  steam,  from  flame, 
from  explosions  of  gunpowder, 
or  of  gas  in  mines,  or  from 
caustic  chemicals — nitric,  sul- 
phuric acids,  caustic  potash,  etc. 
(The  appearances  produced  by 
chemicals  have  been  described 
in  the  chapters  on  General  Sur- 
gery.) The  erythema  of  burns 
of  the  first  degree  is  often 
caused  by  undue  exposure  to 
hot  sunlight  (sunburn)  ;  the 
appearances  are  veil  known  to 
everyone.  Burns  of  the  second 
degree,  with  the  production  of 
blebs,  are  caused  by  the  mo- 
mentary action  of  steam,  hot 
liquids,  or  flame.  Owing  to  the  automatic  closure  of  the  eyelids,  the  eyeball 
usually  escapes  injury.  When  the  individual  is  wrapped  in  flames — as  from 
light  clothing  catching  fire — extensive  burns  of  the  trunk  and  extremities 
usually  occur,  imperiling  life,  and  the  burn  of  the  face  is  a  minor  part  of  the 


Fig.  159. —  Scars  and  Deformity  Following  Exten- 
sive Burns  of  the  Face  Produced  by  the  Explo- 
sion of  Gas  in  a  Coal  Mine.  The  upper  eyelids  in 
this  case  were  almost  totally  destroyed  and  the  lower 
lip  was  drawn  downward  away  from  the  gums  and 
teeth.  The  eversion  of  the  lower  lids  is  well  shown. 
At  the  time  this  photograph  was  taken  several  plastic 
operations  had  been  done  for  the  restoration  of  the  up- 
per lids  and  for  the  relief  of  the  deformity  of  the 
mouth.  Before  the  deformities  were  all  repaired 
eleven  operations  were  done  by  Dr.  Charles  McBurney. 


DISEASES    OF   THE   EACE  449 

injury.  Epileptics  and  others  who  become  unconscious  may  fall  upon  a  hot 
stove,  or  the  like,  and  receive  localized  deep  burns  of  the  face.  Prolonged  ex- 
posure to  steam,  flame,  etc.,  the  caustic  acids  and  alkalis,  and  powder  and  other 
explosions,  usually  produce  deep  burns  with  the  formation  of  eschars.  The 
eyes  may  be  destroyed,  and  the  sloughs  may  extend  to  or  involve  the  bones. 

The  principal  interest  attaching  to  these  burns  lies  in  the  danger  of  infec- 
tion during  the  separation  of  the  sloughs,  and  in  the  scars  which  are  left  behind. 
The  subsequent  contraction  of  such  scars  produces  deformities,  such  as  eversion 
of  the  lower  eyelid  (ectropion).  Partial  destruction  of  the  upper  lid,  and 
inability  to  close  the  eye  and  properly  cover  the  cornea,  lead  to  ulceration  of 
the  cornea.  Eversion  of  the  lower  lip  follows  burns  of  the  lip  and  chin.  The 
mouth  may  be  drawn  to  one  side,  or  the  size  of  the  orifice  may  be  diminished, 
or  the  chin  may  be  drawn  downward  toward  the  sternum,  the  nostrils  may  be 
deformed  or  closed.  Deep  scars  upon  the  cheeks  may  lock  the  lower  jaw,  so 
that  the  teeth  cannot  be  properly  separated,  etc. 

Freezing  of  the  Face. — Exposure  to  extreme  cold  may  freeze  portions  of  the 
face;  the  tip  of  the  nose  and  the  upper  rim  of  the  ear  are  the  parts  most  com- 
monly frozen,  less  often  the  cheeks.  Some  loss  of  substance  may  follow.  Par- 
tial frostbite  may  render  the  nose  and  ears  unduly  sensitive  to  cold  for  some 
time.  The  tip  of  the  'nose  may  be  left  in  a  more  or  less  chronic  state  of  con- 
gestion and  redness;  or  chilblains — a  tendency  to  swelling,  and  redness  of  the 
part  after  slight  chilling — may  remain  for  some  time. 

DISEASES    OF    THE    FACE 

Furuncle  and  Carbuncle  of  the  Face. — Furuncle  occurs  upon  the  face,  nota- 
bly upon  the  upper  lip,  the  tip  and  filtrum  of  the  nose,  less  often  on  the  cheeks. 
The  signs  and  symptoms  do  not  differ  from  those  of  furuncle  elsewhere,  except 
that  here  they  are  quite  painful  and  very  tender.  Carbuncle  of  the  lip  consists 
of  a  congeries  of  furuncles.  The  whole  thickness  of  the  lip  may  be  infiltrated 
and  converted  into  a  dense  brawny  mass  of  infected  tissue,  the  pain  is  marked, 
and  the  constitutional  symptoms  are  severe.  In  bad  cases  the  condition  may 
cause  death  by  acute  sepsis,  or  by  thrombophlebitis,  extending  from  the  angular 
vein  into  the  ophthalmic  vein,  and  thus  into  the  cavernous  sinus,  with  pyemia 
and  meningitis ;  or  downward,  through  the  facial  vein,  into  the  internal  jugu- 
lar. The  course  of  the  thrombophlebitis  can  sometimes  be  made  out  by  finding 
a  eordlike  mass  of  infiltration  in  the  course  of  the  vein.  Edema  and  infiltra- 
tion of  the  eyelids  point  to  phlebitis  in  the  orbit ;  infiltration  in  the  submax- 
illary region,  to  infection  through  the  facial  vein. 

In  these  cases  a  rapidly  progressive  septic  phlegmon  of  the  tissues  of  the 
face  and  neck  may  begin  as  such,  under  stormy  symptoms  of  local  pain,  ten- 
derness, and  swelling,  or  an  ordinary  acne  pustule,  furuncle,  or  carbuncle,  may 
suddenly  assume  a  malignant  form.  The  pus-producing  organisms,  usually 
Staphylococus  pyogenes  aureus,  or,  less  often,  Pyogenes  albus,  are  the  cause 
30 


450  INJURIES   AND   DISEASES    OF   THE   FACE 

of  the  infection.  The  condition  is  commonly  spoken  of  as  malignant  pustule 
of  the  lip,  but  has  no  relation  to  true  malignant  pustule  (anthrax).  De- 
pressed conditions  of  health,  notably  diabetes,  favor  the  occurrence  of  these 
malignant  infections.  Local  conditions  favoring  the  occurrence  of  furuncle 
and  carbuncle  are  a  dirty  skin,  eczema,  sycosis,  and  acne  of  the  face.  The 
infection  is  often  caused  by  scratching  with  dirty  finger  nails,  infected  per- 
haps from  handling  other  purulent  foci. 

Anthrax  of  the  Face. — Anthrax  occurs  chiefly  among  those  who  handle 
the  hides,  the  bodies,  or  the  feces  of  infected  animals.  The  infected  fingers 
carry  the  bacilli  to  some  minute  abrasion  on  the  face.  It  is  believed  that 
the  bites  of  infected  flies  may  transmit  anthrax.  The  pustule  occurs  upon 
the  face  in  nearly  one  third  of  all  cases.  In  from  twenty-four  hours  to  five 
or  six  days  after  infection,  a  red  papule  appears  at  the  site  of  inoculation, 
accompanied  by  intense  itching.  In  a  few  hours  a  vesicle  appears  on  the 
papule ;  the  swelling  and  redness  spread  superficially  and  deeply.  The  vesicle 
bursts  and  discharges  a  little  blood-stained  fluid  containing  many  anthrax 
bacilli,  leaving  behind  a  depressed  ulcer,  the  base  of  which  rapidly  dries  into 
a  black  crust;  an  intensely  red,  hard  area  of  infiltration  surrounds  the  pus- 
tule. Upon  the  surface  of  the  area  a  circular  row  of  secondary  vesicles  appear ; 
there  is  added  edema  of  the  neighboring  tissues  and  enlargement  of  the  lym- 
phatic glands.  The  necrotic  area  of  the  pustule  may  increase  to  the  size  of 
a  silver  dime,  or  of  a  twenty-five-cent  piece,   sometimes  larger. 

The  cases  may  be  divided  into  two  groups:  those  in  which  the  bacilli 
remain  localized  in  the  pustule,  and  those  in  which  they  are  disseminated 
rapidly  in  the  subcutaneous  tissues,  with  the  production  of  a  progressive 
brawny  edema,  which  advances  in  all  directions,  and  is  accompanied  by  pro- 
found constitutional  symptoms,  and  final  dissemination  of  the  disease  through 
the  blood-vessels,  with  fatal  infection  of  the  entire  organism,  as  already  de- 
scribed in  the  section  on  Anthrax.  (See  Anthrax,  General  Surgery.)  The 
localized  cases  may  remain  with  few  or  no  constitutional  symptoms  for  many 
days.  The  process  may  then  proceed  to  healing  with  the  death  of  the  bacilli, 
or  dissemination  may  finally  take  place.  The  diagnosis  is  established  readily 
enough  by  the  history,  by  the  character  of  the  pustule,  by  finding  the  bacilli 
in  the  discharge,  or  in  scrapings  from  the  base  of  the  pustule,  or  in  sections 
of  the  excised  pustule,  or  by  inoculating  a  mouse.  It  is  worth  remembering 
that  not  every  pustule  with  a  black  crust  which  appears  upon  the  face  is 
anthrax.  A  very  similar  appearance  to  an  anthrax  pustule  in  its  early  stages, 
before  the  formation  of  secondary  vesicles,  may  be  caused  by  Staphylococcus 
pyogenes  aureus. 

Glanders. — Glanders  has  already  been  described  in  a  separate  section.  In 
man,  the  infection  takes  place  through  minute  wounds  or  abrasions,  usually 
of  the  hands  and  face.  The  pustules  of  the  face  occur  upon  the  general  integu- 
ment, upon  the  mucous  membrane  of  the  nose,  the  mouth,  and  the  conjunctiva. 
As  already  noted,  the  glanders  pustules  begin  as  nodular  inflammatory  infil- 


DISEASES    OF    THE   FACE 


451 


trations,  which  hreak  down,  and  may  undergo  a  rapid  and  destructive  ulcera- 
tion; diffuse  phlegmonous  infiltrations  may  also  occur  resembling  phlegmonous 
erysipelas.      (For   further    information,    see   section   on    Glanders.) 

Actinomycosis  of  the  Face.  (See  Actinomycosis.)  Erysipelas  of  the  Face. 
(See  Erysipelas.)  lupus  of  the  Face.  (See  Lupus.)  Noma  of  the  Face.  (See 
Noma.) 

Syphilis  of  the  Face. — As 
already  noted,  the  lower  lip 
is  a  frequent  site  for  the  ini- 
tial lesion  of  syphilis.  A  his- 
tory of  the  source  of  infection 
may  often  be  obtained.  After 
the  period  of  incubation  is 
passed  chancre  of  the  lip  de- 
velops as  a  somewhat  indu- 
rated or  elastic  nodule,  which 
slowly  increases  in  size,  is 
painless  and  insensitive,  near- 
ly always  ulcerates,  leaving 
a  superficial,  round,  or  oval, 
raw  surface,  of  the  character- 
istic ham-colored,  moist  char- 
acter. The  surface  bleeds 
readily,  and  often  becomes 
covered  by  a  yellowish  crust. 
Enlargement  and  induration 
of  the  submental  and  sub- 
maxillary lymph  glands  ap- 
pears during  the  first  week 
or  two.  These  glands  often 
reach  a  considerable  size; 
they  are  painless  and  insensi- 
tive, rarely  suppurate.  From 
carcinoma  of  the  lip,  chan- 
cre can  usually  be  differentiated  by  the  age  of  the  patient,  by  the  fact  that 
chancre,  after  reaching  a  certain  size,  ceases  to  extend ;  whereas,  cancer  ad- 
vances continually.  In  cases  of  doubt,  a  microscopic  examination  of  a  small 
portion  of  the  infiltrated  tissue  will  make  the  diagnosis  clear. 

The  secondary  lesions  of  syphilis — papular  and  pustular  eruptions — occur 
especially  on  the  forehead  along  the  border  of  the  hair,  upon  the  cheeks  near 
the  nose,  and  elsewhere.  Their  characteristic  appearances  and  arrangement 
are  described  under  Syphilis,  as  well  as  those  of  the  papules  upon  the  mucous 
membrane  of  the  mouth,  lips,  tongue,  and  pharynx,  commonly  known  as 
mucous   patches.      These   form    one    of   the   most   constant    and    characteristic 


Fig.  160. — Noma,  Gangrene  of  the  Cheek  and  Lips.  The 
child  was  ten  years  of  age  and  was  brought  to  the  hospital 
with  a  gangrenous  lesion  fully  developed,  as  shown  in  the 
photograph.  The  entire  thickness  of  the  cheek  was  necrotic, 
and  during  the  twenty-four  hours  which  intervened  before 
the  patient's  death  the  gangrenous  process  spread  rapidly. 
Extreme  constitutional  depression  existed  so  that  no  op- 
erative procedures  were  possible.  The  child  was  stupid 
and  did  not  seem  to  suffer  pain.  She  died  about  four  hours 
after  the  photograph  was  taken.  No  special  cause  could 
be  learned  for  the  occurrence  of  the  lesion.  (Author's  col- 
lection.) 


452 


INJUEIES   AND   DISEASES    OF   THE   FACE 


lesions  of  the  disease,  and  are  usually  found  at  some  period  during  the  sec- 
ondary stage. 

The  tertiary  lesions  of  syphilis — gummata  of  the  soft  parts  of  the  bones — 
are  frequent  upon  the  face,  both  in  the  acquired  and  hereditary  forms  of  the 
disease.  Gumma  is  recognized  here,  as  elsewhere,  by  the  punched-out  appear- 
ance of  the  ulcers;  the  induration  of  the  border  of  the  ulcer,  characteristic  of 
cancer,  is  wanting.  The  base  of  the  ulcer  consists  of  adherent  necrotic  tissue, 
the  edges  are  undermined.  When  progressive,  the  ulceration  is  more  rapid 
than  in  cancer.  Certain  forms  of  gummatous  ulceration  upon  the  lips,  cheeks, 
and  nose  resemble  epithelioma  to  some  extent.  Large  doses  of  iodid  cause 
these  ulcers  to  heal.  A  fragment  of  tissue  may  be  removed  and  examined 
microscopically. 


Fig.  161a. — Dermoid  Cyst  of  the  Septum  of       Fig.  161t. — Besitlt  of  Operation  in  Dr.  Eliot's 
the    Nose.       (Collection    of    Dr.   Ellsworth  Case  of  Dermoid  Cyst  of  the  Nose. 

Eliot.) 

It  happens  sometimes  that  chronic  syphilitic  ulcers  may  become  the  seat 
of  cancer.  Characteristic  round  white  scars  are  often  present  in  syphilis, 
on  the  face,  the  shins,  and  elsewhere.  In  tertiary  syphilis  the  secondary  en- 
largement of  lymph  nodes,  present  in  cancer,  are  usually  wanting.  The  bones 
of  the  nose,  and  the  hard  and  soft  palate,  are  often  attacked  by  syphilis.  As 
pointed  out  in  another  place,  the  syphilitic  nose  with  sunken  bridge  is  char- 
acteristic. A  nose  destroyed  by  lupus  looks  as  though  it  had  been  shaved  off, 
the  destruction  affecting  the  soft  parts  chiefly.  The  necrotic  processes  of 
syphilis  attacking  the  nasal  septum,  palate,  etc.,  often  begin  quite  insidiously 
with  the  symptoms  of  nasal  catarrh.  As  soon  as  ulceration  of  the  mncons  mem- 
brane establishes  communication  with  the  necrotic  bone,  the  stinking  putrid 
odor  of  the  breath  becomes  characteristic. 

Gummata  of  the  face  in  hereditary  syphilis  sometimes  produce  most  hideous 
deformities  with  destruction  of  the  features,  and  subsequent  contraction  of  scar 


TUMORS    OF   THE   FACE 


453 


tissue,  such  that  the  disfigurement  is  of  an  indescribably  horrible  character. 
Deep-seated  gummata  of  the  face,  notably  those  connected  with  the  jaws  and 
the  masseter  muscles,  etc.,  may  form  solid  tumors  of  considerable  size,  and 
unless  they  soften,  discolor  the  skin  and  ulcerate,  may  simulate  malignant 
growths  or  actinomycosis.  In  cases  of  doubt,  active  mercurialization  and  the 
use  of  the  iodids,  together  with  search  for  other  signs  of  syphilis,  will  help  the 
diagnosis. 

TUMORS    OF    THE    FACE 

Lipoma. — I  have  already  spoken  of  lipoma  of  the  forehead.  Lipomata 
may  also  rarely  occur  in  the  parotid  region  and  upon  the  chin.  They  occur, 
rarely,  as  subcutaneous  or  submucous  tumors  in  the  lips  and  eyelids,  and  upon 
the  bridge  of  the  nose.  The  deep  lipoma  of  the  cheek  may  present  more  promi- 
nently in  the  mucous  membrane  of  the  mouth,  or  upon  the  cheek,  in  the  neigh- 
borhood of  the  anterior  bor- 
der of  the  masseter  muscle. 
Combinations  with  fibroma 
and  angioma  may  occur. 
Inasmuch  as  the  lobulated 
structure  of  lipoma  is  some- 
times wanting,  the  diagnosis 
is  not  always  easy ;  they  are 
often  taken  for  dermoids,  or 
mucous  cysts,  or  even  for 
chronic  abscesses.  The  very 
slow  growth,  puncture  with 
an  aspirating  needle,  and, 
finally,  incision,  may  be  nec- 
essary for  a  diagnosis. 

Fibroma. — Both  hard  and 
soft  fibromata  occur  upon 
the  face.  Of  the  hard  form, 
'keloid  is  the  most  common; 
it  frequently  develops  in  the 
lobule  of  the  ear,  in  the  scar 
left  after  boring  the  lobule 
for  earrings.  The  tumors 
are  of  small  size,  firm,  pain- 
less, and  insensitive,  of  slow 
growth,    and    of   a    pink   or 

red  color.  They  may  appear  elsewhere  on  the  face  in  the  scars  of  wounds. 
The  soft  fibroma  occurs  upon  the  face  in  the  form  of  fibroma  molluscum  (Cutis 
pendula),  as  single  or  multiple  tumors,  of  slow  growth,  which  may  reach  in 
time  a  very  large  size   and  produce  large,   soft,   pendulous   masses,    covered 


Fig.  162. — Congenital  Mixed  Lymph  and  Venous  Angi- 
oma of  the  Face,  Inoperable.  (New  York  Hospital 
collection.) 


454 


INJURIES    AND    DISEASES    OF    THE   EACE 


by  loose,  flabby  skin,  which  hang  down  in  folds,  causing  peculiar  and 
characteristic  deformities.  These  fibromata  also  occur  in  combination  with 
neurofibroma,  plexiform  neuroma.  In  these  cases  the  bundles  of  enlarged 
and  thickened  nerves  can  sometimes  be  felt  subcutaneously  in  the  tumor  mass 
like  a  bundle  of  angleworms.  Combinations  also  occur  with  angioma,  lym- 
phangioma, and  myxoma.  Some  of  the  hairy  and  pigmented  moles  are  soft 
fibromata  or  combinations  of  fibroma  with  angioma.  The  congenital  enlarge- 
ments of  the  upper  and  lower  lip  are  fibromata  in  combination  with  lymphan- 
gioma and  angioma  (macrochelia).     (See  Tumors.) 

Sarcoma. — The  majority  of  sarcomata  occurring  in  the  face  have  their 
origin  in  bone.  The  sarcomata  of  the  soft  parts  originate,  not  infrequently, 
in  pigmented  moles  or  nevi,  and  are  then,  as  a  rule,  of  the  melanotic  type. 
As  described  under  Tumors,  they  are  of  rapid  growth,  and  produce  multiple 

pigmented  tumors  in  the  vicinity. 
Early  dissemination  with  widespread 
metastasis  is  the  rule. 


Fig.  163. — Cavernous  Lymphangioma  of  the  Face, 
Congenital.  Child  eighteen  months  old.  The 
portion  of  the  growth  above  the  eye  was  removed 
by  operation.  The  patient  did  not  survive.  (Col- 
lection of  Dr.  F.  W.  Murray.) 


Fig.  164. — Congenital  Lymphangioma  of  the 
Upper  Lip  (Macrocheilia)  in  a  Little 
Girl.  (Collection  of  Dr.  Charles  McBur- 
ney.) 


Lymphangioma. — Lymphangiomata,  either  simple,  cavernous,  or  cystic,  occur 
in  the  upper  and  lower  lip  and  in  the  cheeks.  Some  of  the  cases  of  macrocheilia 
belong  to  this  group.  The  lymphangioma  simplex  and  lymphangioma  cav- 
ernosa sometimes  form  diffuse  tumors.  The  cystic  lymphangioma  are  usually 
circumscribed.  Combination  forms  also  occur;  they  are  often  small,  circum- 
scribed, congenital  tumors  of  the  face  and  lips,  which  subsequently  take  on 
a  slow  growth,  and  may  involve,  in  time,  the  greater  portion  or  half  of  the 


TUMORS    OF   THE   FACE  455 

face.  The  skin  over  the  tumor  is  normal  and  smooth,  and  being  adherent, 
or  forming  a  part  of  the  growth,  it  does  not  wrinkle  when  the  tumor  is  moved 
or  compressed.  They  are  soft  and  spongy  tumors,  which  diminish  in  size  on 
pressure.  They  are  to  be  distinguished  from  hemangiomata  by  the  blue  or  red 
color  of  the  latter,  the  combination  forms  of  lymphangiomata  with  hemangi- 
omata, being  pale  pink,  red,  or  light  blue,  according  to  the  relative  proportion 
of  lymph  and  blood-vessels.  Existing  in  combination  with  fibroma  and  lipoma, 
they  give  rise  to  tumors  having  the  characters  of  cutis  pendula,  or  elephantiasis 
of  the  face. 

The  cystic  lymphangioma,  occur  most  often  in  the  cheeks,  and  are  con- 
genital, or  develop  from  the  cavernous  form.  They  give  the  characters  of 
cystic  tumors  under  no  great  tension,  containing  lymph.  The  skin,  or  mucous 
membrane,  may  be  so  thinned  over  them  that  they  are  plainly  translucent. 
These  angiomata  often  become  infected  through  abrasions,  etc.  The  infection 
gives  rise  to  signs  of  inflammation  in  the  tumor  which  lasts  for  a  certain  time, 
is  followed  by  resolution  or  by  suppuration.  The  attacks  of  inflammation 
may  lead  to  an  intermittent  progressive  enlargement  of  the  growth.  While 
the  diagnosis  is  usually  easy,  they  may  be  confounded  with  cystic  tumors  of 
the  parotid  gland,  or  with  branchio-genetic  cysts,  and  the  diagnosis  may  only 
be  made  by  microscopic  examination.  Mucous  cysts  of  the  mouth  may  occur 
immediately  beneath  the  mucous  membrane  of  the  lip.  Their  contents  are 
mucus,  not  lymph. 

Acne  Rosacea.- — The  highly  developed  forms  of  acne  rosacea  which  are 
seen  in  elderly  people  and  form  a  peculiar  red  knobby  enlargement  of  the 
nose  consist  of  an  hypertrophy  of  the  connective  tissue,  dilatation  of  the 
small  blood-vessels,  and  hypertrophy,  or  cystic  degeneration  of  the  se- 
baceous glands.  The  orifices  of  the  glandular  organs  of  the  skin  are 
frequently  dilated  into  pits,  and  give  the  enlargement  a  peculiar  spongy 
appearance. 

Angiomata  of  the  Face. — The  face  is  a  favorite  seat  for  angiomata.  Angi- 
oma simplex  occurs  upon  the  face  congenitally  in  the  well-known  form  of 
tier  us.  The  tumors  form  larger  or  smaller,  flat,  moderately  elevated,  or,  more 
rarely,  prominent  and  lobulated,  pink,  red,  or  purple  red,  soft  tumors  upon 
the  skin  of  the  face,  the  forehead,  the  eyelids,  the  nose,  the  lips,  the  chin. 
The  spot  may  be  no  larger,  or  scarcely  larger,  than  a  flea  bite,  at  birth,  and 
may  remain  stationary,  or  grow  quite  rapidly  during  the  first  years  of  life, 
so  that  it  involves  a  considerable  portion  of  the  face.  They  are  often  pig- 
mented, and  sometimes  are  covered  with  an  abundant  growth  of  fine  soft  hair. 
They  are  popularly  believed  to  arise  from  maternal  impressions.  Many  of 
these  tumors  are  of  considerable  size  at  birth,  and  only  slowly  increase  with 
the  growth  of  the  individual.  Sometimes  the  angiomata  begin  in  the  subcu- 
taneous tissues,  and  only  reach  the  skin  after  some  time,  so  that  there  may 
gradually  appear  over  the  surface,  here  and  there,  faintly  red  or  blue  spots, 
which  increase  in  size  and  color  when  the  child  cries.     Later  on,  these  tumors 


456 


INJURIES    AND   DISEASES    OF   THE   FACE 


may  grow  outward  and  form  red   or  blue  lobulated  masses.      Such  tumors 
occur  most  often  on  the  eyelids,  lips,  cheeks,  and  nose. 


Fig.  165. — Congenital  Angioma  of  the  Ear.     (Collection  of  Dr.  Charles  McBumey.) 


The  cavernous  angioma  of  the  face 
often  forms  tumors  of  considerable  size 


Fig.  166. — Rapidly  Growing  and  Malignant  Form 
of  Epithelioma  of  the  Cheek.  (Collection  of 
Dr.  Charles  McBurney.) 


occurs  especially  upon  the  lips,  and 
involving  the  whole  thickness  of  the 
lip  and  forming  spongy,  soft  blue 
masses.  They  swell  with  the  in- 
crease of  venous  pressure  in  crying, 
coughing,  etc.,  and  diminish  in  size 
when  compressed  between  the  fin- 
gers. They  are  sometimes  painful. 
They  may  gradually  grow,  and  oc- 
cupy a  considerable  portion  of  the 
face  and  neck.  The  arterial  angi- 
omata  have  been  spoken  of  under 
the  head  of  Cirsoid  Aneurism. 

Epithelial  Tumors  of  the  Face. — 
Epithelial  tumors  of  the  face  oc- 
cur in  both  benign  and  malignant 
forms.  Among  the  benign  tumors 
are  horns.  They  occur  most  often 
upon  the  forehead,  less  often  upon 
the  lips  and  in  other  situations. 
Old  women  are  usually  affected. 
Sebaceous  cysts  occur  upon  the  face 
much  less  often  than  upon  the 
scalp.  They  occur  in  front  of  the 
ear,  in  the  cheeks,  in  the  lips. 
They  do  not  reach  so  large  a  size 


TUMORS    OF    THE   FACE 


457 


as  upon  the  scalp,  but  possess  the  same  clinical  character.-.  Warts  quite 
commonly  occur  upon  the  face  in  various  forms,  both  hard  and  soft,  some- 
times pigmented  and  hairy.  They  may  give  rise  to  epithelioma,  as  has  al- 
ready been  noted.  Retention  cysts  in  the  hair  follicles  constitute  the  well- 
known  "  black  heads,"  or  comedones.  Retention  cysts  of  the  sebaceous  glands 
constitute  the  little  white,  pearly  tumors  not  infrequently  found  upon  the  skin 
of  the  face  {milium). 

Adenoma  of  the  Sweat  Glands. — They  form,  according  to  the  description  of 
Stilling,  small,  slightly  elevated,  sharply  circumscribed,  nodular,  or  sausage- 
shaped  elevations  upon  the  skin. 
They  develop  slowly  near  the  eye 
and  the  angle  of  the  jaw  in  old 
people.  They  bear  a  certain  clin- 
ical resemblance  to  lupus.  Ade- 
nomata of  the  sebaceous  glands  oc- 
cur in  the  eyelids  and  upon  the  nose. 
They  form  wartlike  or  knobby  little 
tumors,  varying  in  size  from  a  pea 
to  a  walnut,  and  possess  a  true 
adenomatous  structure.  They  are 
often  multiple. 

Dermoid  Cysts  of  the  Face. — 
Dermoid  cysts  of  the  face  occur,  as 
already  stated  (Tumors  of  the 
Scalp),  on  the  superior  border  of 
the  orbit  and  at  the  root  of  the 
nose.  They  may  also  occur  in  the 
temporal  region.  They  are  to  be 
distinguished  from  sebaceous  cysts 
by  the  fact  that  they  are  frequently 
congenital,  occur  in  special  situa- 
tions, grow  very  slowly,  are  seldom, 
if  ever,  larger  than  a  walnut,  are 
more  deeply  seated,  often  attached  to  the  bon 
bony  surface. 

Carcinoma. — Skin  carcinoma,  or  epithelioma,  very  frequently  occurs  upon 
the  face,  quite  commonly  at  the  junction  of  the  skin  with  the  mucous  mem- 
brane ;  the  red  border  of  the  lower  lip  and  beneath  the  lower  eyelid,  the  ahe 
of  the  nose,  the  cheeks,  are  all  favorite  sites.  Epithelioma  of  the  upper  lip  is 
a  surgical  curiosity.  Chronic  sources  of  irritation  strongly  predispose  to  the 
occurrence  of  cancer  of  the  face.  I  have  already  referred  to  the  fact  that 
epithelioma  of  the  lower  lip  nearly  always  appears  in  pipe-smokers.  Any  one 
of  the  benign  forms  of  epithelioma  already  spoken  of  may  become  the  seat  of 
cancer.     Warts,  horns,  hypertrophy,  or  disease  of  the  glandular  elements  of 


Fig.  167.- 


Early  Stage   of  Epithelioma  of  the 
Lip.      (Author's  collection.) 

—sitting  in  a  depression  of  the 


458 


INJURIES    AND   DISEASES    OF    THE   FACE 


Fig.  168a. — Epithelioma  of  the  Lower  Lip. 
(Collection  of  Dr.  Charles  McBurney.) 


to  invade  the  deeper  tissues,  to  in- 
fect the  lymph  nodes,  and  cause 
general  carcinosis. 

Flat  Form  of  Carcinoma. — 
The  flat  form  of  carcinoma,  al- 
ready described  under  the  head  of 
Rodent  Ulcer,  presents  itself  as  an 
indurated  nodule,  or  larger,  flat, 
slightly  elevated  area  of  infiltrated 
tissue  which  finally  undergoes  ul-, 


ceration.  The  edges  of  the  ulcer 
are  slightly  hard  and  elevated; 
the  skin  around  the  ulcer  is  often 
drawn  into  little  wrinkles  by  cica- 
tricial contraction.  In  the  early 
stages  the  ulcer  is  covered  by  a 
crust;  beneath  the  crust  there  ac- 
cumulates a  little  purulent  dis- 
charge.    The  spread  of  the  ulcer  is 


the  skin,  sebaceous  cysts,  chronic 
skin  diseases — eczema,  psoriasis — 
repeated  attacks  of  erysipelas, 
syphilitic  or  tubercular  ulcerations, 
scars,  chronic  patches  of  seborrheic 
eczema,  all  may  give  rise  to  the 
development  of  cancer,  and  this 
list  might  be  enlarged.  The  dis- 
ease is  one  of  advanced  life,  al- 
though it  may  occur  rarely  in 
young  persons.  I  have  seen  an 
epithelioma  of  the  lower  lip  in  a 
man  of  twenty-eight  years,  and 
have  recently  operated  upon  an- 
other aged  twenty-seven.  Two 
forms  are  to  be  distinguished :  the 
slowly  growing,  superficial  form — 
flat  carcinoma — and  the  more  ma- 
lignant form  which  tends  rapidly 


Fig.  1686. — Profile  View  of  the  Same  Patient 
as  Fig.  168a.  (Roosevelt  Hospital,  collection  of 
Dr.  Charles  McBurney.) 


TUMORS    OF    THE    FACE 


459 


usually  very  slow,  and  there  is  a  tendency  for  the  older  portions  to  heal  with 
marked  cicatricial  contraction.  This  form  of  epithelioma  especially  affects 
the  forehead,  the  temple,  the  ala?  of  the  nose,  the  eyelids,  and  the  cheeks.  It 
is  sometimes  curable  by  means  of  the  X-rays  and  radium.  The  disease  may 
spread  superficially  for  many  years,  but  after  a  time  tends  to  invade  and  destroy 
the  deeper  structures  (see  Tumors).  Infection  of  the  lymph  nodes  occurs 
late  or  not  at  all. 

Deep  or  Infiltrating  Form  of  Carcinoma  of  the  Face. — The  deep 
or  infiltrating'  form  of  carcinoma  of  the  face  has  its  especial  home  upon  the 
lower  lip ;  it  is  in  every 
way  a  progressive,  infec- 
tious, and  surely  fatal  dis- 
ease, unless  removed  by  an 
early  and  thorough  opera- 
tion. It  is  one  of  the  forms 
of  carcinoma  which  is  not 
cured  by  the  X-rays.  As 
occurring  upon  the  lip,  it  is 
rare  before  forty  years  of 
age.  There  forms  upon  the 
red  border  of  the  lip — often 
just  to  one  side  of  the  me- 
dian line,  never,  as  far  as 
I  am  aware,  at  the  corner 
of  the  mouth,  sometimes 
upon  the  site  of  a  chronic 
fissure  of  the  lip,  or  where 
the  epithelial  covering  has 
become  thickened  or  horny 
from  chronic  irritation — an 
indurated  plaque,  which 
soon  develops  into  a  nodule 
involving  a  considerable 
part  or  the  whole  thick- 
ness of  the  lip.  The  sur- 
face of  the  nodule  soon 
breaks  down  and  forms  an  ulcer  with  indurated  base  and  borders.  Upon 
the  surface  of  the  ulcer  minute  white  points  can  sometimes  be  seen,  and 
pressure  may  cause  the  extrusion  of  columns  or  nests  of  epithelial  cells. 
Papillary  outgrowths  rarely  occur  in  the  epithelioma  of  the  lip. 

The  progress  of  the  disease  is  fairly  rapid  and  the  infiltrated  and  ulcerated 
areas  may  reach  large  dimensions  in  a  few  months.  The  lymphatic  glands 
beneath  the  chin  and  in  the  submaxillary  region  soon  become  enlarged  and 
hard.     If  the  growth  is  not  removed,  the  entire  lip  and  chin,  the  mucous  mem- 


Fig.  169. — Epithelioma  of  the  Lower  Lip. 
(Author's  collection.) 


460  INJURIES   AND   DISEASES    OF   THE   EACE 

brane  of  the  mouth,  and  the  jaw  are  infiltrated.  Ulceration  in  the  interior 
of  the  mouth  causes  the  breath  to  become  offensive.  The  patient  begins  to 
suffer  from  chronic  sepsis.  The  cancerous  tumors  of  the  neck  increase  in  size, 
break  down  and  ulcerate,  and  add  to  the  miseries  of  the  patient.  Death  occurs 
from  chronic  sepsis,  from  hemorrhage,  from  exhaustion,  from  aspiration  pneu- 
monia, from  asphyxia,  usually  before  metastases  in  internal  organs  have  had 
time  to  destroy  life. 

INJURIES    AND    DISEASES    OF    THE    ORBIT 

Wounds  of  the  Orbit. — Wounds  of  the  orbit  are  interesting  from  the  fact 
that  they  are  sometimes  accompanied  by  perforation  of  the  wall  of  the  orbit 
and  injury  of  the  brain.  The  gunshot  and  punctured  wounds  are  particularly 
interesting  in  this  connection.  As  the  result  of  infected  wounds  of  the  orbit, 
or  infectious  processes  originating  in  the  orbit  or  in  the  vicinity,  suppuration 
of  the  tissues  of  the  orbit  may  take  place,  not  infrequently  with  infection 
through  the  ophthalmic  vein,  sinus  thrombosis,  meningitis,  and  pyemia.  The 
symptoms  of  phlegmon  of  the  orbit  are  severe  pain,  fever,  edema  of  the  eyelids, 
swelling  of  the  conjunctiva,  exophthalmos,  immobility  of  the  eyeball,  and 
diminution  or  loss  of  vision.  Invasion  of  the  interior  of  the  skull  is  char- 
acterized by  the  symptoms  described  under  appropriate  headings.  The  pres- 
ence of  foreign  bodies  in  the  orbit,  if  metallic^  can  usually  be  located  by  means 
of  the  X-rays.  For  the  injuries  and  diseases  of  the  eyeball  itself  the  reader 
is  referred  to  special  works  on  the  topic. 

As  the  result  of  wounds  and  fractures  of  the  skull,  an  arterio-venous  aneu- 
rism may  develop  between  the  cavernous  sinus  and  the  internal  carotid  artery. 
The  signs  and  symptoms  are  as  follows:  There  is  exophthalmos;  the  eyeball 
pulsates,  and  the  pulsation  can  be  both  seen  and  felt;  the  eyelids  are  swollen; 
there  is  often  ectropion  of  the  lower  lid ;  pressure  on  the  common  carotid  artery 
of  that  side  stops  the  pulsation;  vision  may  be  normal  or  diminished.  Emphy- 
sema of  the  loose  tissues  of  the  orbit  occurs  as  the  result  of  fractures,  or  per- 
forations from  disease  of  the  walls  of  the  neighboring  air-containing  cavities, 
the  frontal  sinus,  the  antrum  of  Highmore,  the  ethmoid  cells,  fracture  of  the 
lacrymal  bone.  The  symptoms  are  exophthalmos,  usually  emphysema  of  the 
eyelids,  and  more  or  less  immobility  of  the  eyeball,  generally  without  impair- 
ment of  vision. 

Tumors  of  the  Orbit. — Tumors  of  the  orbit  may  arise  in  the  eyeball  itself, 
in  the  other  tissues  of  the  orbit,  or  from  the  neighboring  cavities,  notably  the 
frontal  sinus  and  the  antrum.  Several  varieties  of  sarcoma  originate  in  the 
eyeball,  in  the  optic  nerve,  or  in  the  other  soft  tissues  of  the  orbit — gliosarcoma, 
melano-sarcoma,  and  other  forms.  These  tumors  are  usually  characterized  by 
rapid  growth  and  great  malignancy.  Generally  speaking,  rapidly  growing, 
solid  tumors  of  the  orbit,  which  do  not  pulsate  and  have  an  uneven  surface, 
do  not  contain  fluid ;  of  firm  consistence,  or  more  elastic,  are  sarcomata.     Pul- 


AFFECTIONS  OF  THE  CRANIAL  NERVES  461 

sating  angiosarcomata  also  occur  in  this  region.  With  the  growth  of  the  tumor 
there  is  a  progressive  exophthalmos,  aisturbances  of  vision,  later  blindness, 
involvement  of  the  surrounding  structures,  perforation  of  the  cranial  cavity, 
etc.  Echinococcus  cyst  has  been  observed  in  the  orbit.  The  diagnosis  must 
be  made  upon  the  recognition  of  a  cystic  tumor  from  which  characteristic  fluid 
is  withdrawn.  Dermoids  are  occasionally  observed  in  the  orbit.  Tn  melano- 
sarcoma,  primary  in  the  choroid,  about  twenty-five  per  cent  of  cures  are  ob- 
tained if  the  eyeball  is  removed  very  early. 

AFFECTIONS  OF  THE  FIFTH  AND  SEVENTH  PAIRS  OF  CRANIAL  NERVES 

Neuralgia  of  the  Fifth  Pair  of  Cranial  Nerves. — The  symptoms  of  neuralgia 
of  the  fifth  pair  of  cranial  nerves  consist  of  pain  in  the  distribution  of  one  or 
more  of  the  branches  of  the  nerve.  The  pain  may  be  continuous  or  intermit- 
tent. The  attacks  of  pain  are  usually  brought  on  by  slight  sources  of  external 
irritation,  such  as  motion,  pressure,  a  draught  of  cold  air,  or  mental  excitement. 
The  motions  of  the  jaws  in  eating  may  excite  pain.  In  addition  to  the  pain, 
there  are  sometimes  associated  spasmodic  contractions  of  the  muscles  supplied 
by  the  facial  nerve.  Serious  interference  with  the  general  health  appears  in 
chronic  or  severe  cases.  The  characteristic  feature  of  the  attacks  are  their 
lightninglike  suddenness  and  often  agonizing  severity.  The  duration  of  the 
attacks  is  variable — seconds,  minutes,  or  hours. 

The  causes  of  these  neuralgias  are  very  various.  They  may  be  due  to 
diseases  of  the  brain,  syphilis,  the  presence  of  tumors,  or  other  intracranial 
diseases ;  they  sometimes  depend  upon  general  conditions  of  the  organism,  such 
as  autointoxication  from  constipation  of  the  bowels,  anemia,  hysteria,  chronic 
malarial  poisoning,  and  other  general  states  of  depression.  It  is  of  course 
highly  important  to  exclude  such  general  causes  before  submitting  a  patient 
to  surgical  treatment.  The  local  causes  are  inflammation  of  the  sheath  of  the 
nerve  itself,  which  may  be  due  to  local  irritation  or  inflammation  in  the  region 
of  distribution  of  the  nerve,  such  as  diseases  of  the  teeth  and  jaws,  pressure 
upon  the  nerve  by  scars,  inflammatory  exudates,  or  tumors.  It  is  not  always 
possible  to  determine  whether  the  neuralgia  is  of  a  central  or  peripheral  origin. 
In  seeking  for  a  central  cause  it  is  necessary  to  exclude  the  local  causes  already 
mentioned,  as  well  as  the  general  diseases  and  conditions  which  may  give  rise  to 
neuralgia.  Accompanying  cerebral  symptoms,  or  the  involvement  of  other 
nerves,  would  point  to  a  central  organic  origin. 

In  determining  the  question  of  which  branch  of  the  nerve  is  at  fault,  the 
history  is  important.  In  the  early  stages  of  the  disease  the  pain  may  have  been 
confined  to  but  one  branch,  and  only  have  involved  the  other  branches  of  the 
nerve  at  a  later  period.  Sometimes  there  exist  painful  points ;  for  example, 
pressure  upon  the  supra-orbital  nerve  at  its  exit  from  the  orbit,  upon  the  infra- 
orbital nerve  at  the  infra-orbital  foramen,  or  upon  the  mental  nerve  at  the  side 
of  the  chin  may  always  give  rise  to  an  attack.     On  the  other  hand,  the  patient 


462 


INJURIES   AND   DISEASES    OF   THE   EACE 


may  not  be  able  to  localize  the  pain  in  one  particular  branch.  Sometimes  that 
branch  of  the  nerve  in  which  the  trouble  has  originated  remains  tender  between 
the  attacks  of  pain.  In  some  cases  pressure  upon  the  nerve  which  was  the 
original  seat  of  the  disease  will  cause  diminution  of  the  pain.  During  the 
attacks  of  pain  there  occur  vasomotor  and  trophic  disturbances,  redness  of 
the  conjunctiva,  an  increased  secretion  of  tears,  nasal  mucus,  and  saliva.  Some- 
times flushing  of  the  face,  a  sensation  of  warmth,  and  an  increase  of  perspira- 
tion. Sometimes  herpes  vesicles  develop  in  the  distribution  of  the  nerve,  nota- 
bly upon  the  forehead. 

In  attempting  to  locate  the  cause  of  the  trouble  in  one  particular  branch 
of  the  nerve  it  is  necessary  to  remember  that  a  primarily  local  cause  may  have 
produced  a  neuritis  which  has  spread  and  become  central.  The  more  completely 
all  three  branches  of  the  nerve  are  involved  in  the  neuralgia  the  more  likely 

that  the  disease  can  only  be  re- 
lieved radically  by  an  operation 
upon  the  ganglion.  The  fact  that 
but  a  single  branch  of  the  nerve 
is  involved  does  not  necessarily 
mean  that  the  neuralgia  is  of  pe- 
ripheral origin.  An  intracranial 
irritation  or  pressure  may  be  lim- 
ited to  a  single  branch  of  the  nerve. 
Paralysis  and  Spasm  of  the  Fa- 
cial Nerve. — Paralysis  of  the  facial 
nerve  may  be  of  central  or  periph- 
eral origin.  The  peripheral  causes 
are  wounds  of  the  nerve  in  front 
of  the  ear,  incised  or  stab  wounds 
or  severe  contusions,  fractures  of 
the  base  of  the  skull,  injuries  dur- 
ing surgical  operations  upon  the 
parotid  or  upon  the  jaws,  occasion- 
ally in  operations  for  suppurative 
disease  of  the  middle  ear  and  mas- 
toid ;  diseases  of  the  petrous  por- 
tion of  the  temporal  bone,  syphilis, 
and  tuberculosis,  catarrhal  or  sup- 
purative inflammation  of  the  mid- 
dle ear.  Exposure  to  cold  and  rheumatism  are  believed  also  to  produce 
facial  paralysis.  The  central  causes  are  injuries,  diseases,  and  tumors  of  the 
brain. 

Symptoms. — The  symptoms  of  facial  paralysis  consist  of  paralysis  of  some 
or  all  of  the  muscles  of  the  face,  according  as  a  part  or  the  whole  of  the  nerve 
is  involved.     The  normal  lines — furrows  of  the  face — are  obliterated :  the  sot- 


Fig.  170.  —  Slight  Facial  Paralysis  Following 
Operation  for  Mastoiditis.  The  Nerve  was 
Exposed  in  the  Wound,  bet  not  Cut.  The  pa- 
tient recovered  from  the  paralysis  after  a  few 
weeks.     (Author's  collection.) 


INJURIES   AND   DISEASES    OF   THE   NOSE  463 

face  of  the  skin,  even  in  old  people,  becomes  smooth  and  devoid  of  wrinkles. 
The  upper  eyelid  cannot  be  brought  down  to  close  the  eye.  The  conjunctiva 
is  congested.  The  tears  flow  out  upon  the  cheek.  The  nostril  upon  that  side 
cannot  be  dilated.  The  corner  of  the  mouth  droops.  Saliva  may  drool  from 
the  mouth  on  that  side.  The  mouth  is  drawn  toward  the  sound  side.  The  acts 
of  whistling  and  pursing  up  the  lips  cannot  be  performed.  The  labial  conso- 
nants are  pronounced  with  difficulty,  or  imperfectly.  If  disease  of  the  middle 
ear  exists,  there  may  be  partial  deafness.  There  may  be  disturbances  of 
the  sense  of  taste.  The  movements  of  the  tongue  are  normal.  Paralysis 
of  the  facial  nerve  is  sometimes  one  of  the  symptoms  of  the  so-called  head 
tetanus. 

Spasms  of  the  Muscles  of  the  Face. — Spasms  of  the  muscles  of  the 
face  sometimes  occur  as  the  result  of  direct  or  reflex  irritation  of  the  facial 
nerve.  Such  spasms  occur  frequently  in  neuralgias  of  the  fifth  nerve  as  the 
result  of  reflex  irritation.  The  spasms  consist  of  clonic  contractions  of  the 
muscles  of  the  face — notably  of  the  orbicularis  palpebrarum — and  of  the  mus- 
cles of  the  cheek  and  mouth.  In  case  the  spasm  is  due  to  irritation  of  one 
of  the  peripheral  branches  of  the  fifth  nerve,  pressure  upon  the  nerve  at  the 
point  of  exit  from  its  foramen,  stops  the  spasm.  In  a  few  instances  the  spasm 
may  be  caused  by  direct  irritation  of  the  facial  nerve  itself — a  neuritis. 

INJURIES    AND    DISEASES    OF    THE    NOSE 

Congenital  Defects. — Some  of  the  congenital  defects  of  the  nose  have  already 
been  mentioned  in  speaking  of  the  congenital  fissures  of  the  face.  Absence  of 
the  nose  is  an  exceedingly  rare  congenital  deformity.  Occasionally  a  child  is 
born  with  the  nostrils  abnormally  small,  but  this  deformity  is  more  frequently 
acquired  as  the  result  of  tubercular  or  syphilitic  ulceration.  As  the  result  of 
improper  and  irregular  development  of  the  septum  of  the  nose,  the  bridge  of 
the  nose  may  take  an  oblique  direction  or  be  crooked.  A  moderate  degree 
of  this  deformity  is  by  no  means  uncommon,  but  is  often  so  slight  that  the 
shape  of  the  nose  is  not  altered,  and  the  deformity  of  the  septum  is  only  appre- 
ciated by  looking  into  the  nose  with  a  speculum.  The  entire  bony  framework 
of  the  nose  also  may  have  an  oblique  position,  and  an  ugly  deformity  may 
thus  result. 

Fracture  of  the  Bones  of  the  Nose. — Fracture  of  the  bones  of  the  nose  occurs 
most  often  as  the  result  of  direct  violence  by  blows  and  falls.  The  fracture  is 
usually  compound  into  the  cavity  of  the  nose,  and  is  attended  by  hemorrhage  from 
the  nose  of  greater  or  less  severity.  The  fragments  of  bone  are  usually  displaced 
backward,  causing  a  depression  of  the  nose :  or  backward,  and  to  one  side.  The 
signs  of  fracture — deformity,  abnormal  molality,  and  sometimes  crepitation — 
can  be  discovered  by  inspection  and  palpation.  The  deformity  is  usually  well 
enough  marked  to  be  easily  recognized.  The  cartilaginous  septum  of  the  nose 
may  also  be  fractured,  and  produce  a  bending  of  the  nose  to  one  side. 


464 


INJURIES   AND   DISEASES    OF   THE   FACE 


The  Diseases  of  the  Hose. — The  borders  of  the  nostrils  may  be  the  seat  of 
eczema ;  of  syphilitic,  tubercular,  cancerous,  or  diphtheritic  ulceration ;  as 
well  as  of  the  pustules  of  glanders.  I  have  already  spoken  of  the  peculiar 
hypertrophy  of  the  nose  which  occurs  as  an  extreme  degree  of  acne  rosacea. 
The  noses  of  those  who  habitually  drink  much  alcohol  are  often  swollen  and 
red,  and  dilated  blood-vessels  may  be  seen  in  the  skin.  Diabetics  often  have 
red  noses. 

Lrprs  or  the  Nose  has  already  been  described. 

Syphilis. — Syphilis  in  its  three  stages  may  affect  the  nose.  Chancre  of 
the  nose  is,  however,  extremely  rare.      Secondary  papules,  or,  in  bad  cases, 

ulcerations  with  loss  of  substance, 
involving  the  ala?,  or  the  tip  of  the 
nose,  are  not  uncommon;  and  the 
tertiary  osteitis  and  periostitis  of 
the  nasal  bones,  the  nasal  septum, 
and  the  hard  palate — which  usually 
begin  as  such,  or  are  secondary  to 
ulcerations  of  the  mucous  membrane 
— are  one  of  the  most  characteristic 
lesions  of  tertiary  syphilis.  The 
process  may  be  limited  to  the  nose, 
or  may  involve  the  upper  lip  and 
the  alveolar  process  of  the  upper 
jaw.  The  symptoms  may  come  on 
quite  insidiously,  like  an  ordinary 
catarrh,  and  the  necrosis  of  bone 
may  not  be  recognized  until  too  late 
for  treatment  to  avail.  The  condi- 
tion is  easily  recognizable  in  its  pro- 
gressive  stage   by   the   character   of 

Fig.  171. — Syphilitic  Necrosis  or  the  Nasal  Bones        ,  -■  ..  , 

and  Septum,  Producing  the  Typical  "Saddle-       the    gummatous    ulceration,     by    see- 

f^S^^SiJ^B^f0^1'001'     ing  the   exposed  greenish-yellow   or 

black  bone  through  the  mouth  or 
nose,  and  by  the  horrible  stench  which  accompanies  the  process — of  which, 
fortunately  for  himself,  the  patient  is  unconscious.  After  the  sequestra  have 
separated,  the  well-known  syphilitic  nose,  with  a  depression  where  the  bridge 
should  be,  and  a  turned-up  point,  constitutes  a  deformity  which  needs  only 
to  be  seen  to  be  recognized  (syphilitic  saddle  nose). 

Tumoes  of  the  Nose. — The  same  tumors  occur  upon  the  nose  as  else- 
where upon  the  face. 

RnixoscLEROMA. — Iihinoscleroma  is  a  disease  which  is  caused  by  a  specific 
micro-organism  somewhat  resembling  the  pneumococcus  of  Friedliinder,  but  dif- 
fering from  it.  They  are  short,  oval  rods  surrounded  by  a  capsule.  The  rods 
are  stained  by  Grain's  method  while  the  pneumococcus  is  not.     The  bacillus 


INJUKIES   AND   DISEASES    OF    THE   NOSE  465 

retains  its  capsule  in  the  tissues.  The  disease  apparently  never  originates  in 
the  United  States.  It  occurs  in  Austria  and  Russia  and  in  Central  and  South 
America.  The  disease  begins  upon  the  ahe  or  septum  of  the  nose,  with  the 
formation  of  small,  rounded,  very  firm,  painless  nodules,  which  slowly  in- 
crease in  size,  and  may  in  time  cause  flattening  and  broadening  of  the  nose, 
and  more  or  less  interference  with  breathing  through  the  nostrils.  The  nod- 
ules consist  of  a  reticulum  of  firm  fibrous  tissue ;  the  spaces  are  filled  with 
soft  tissue,  densely  infiltrated  with  small  rounded  cells  and  with  much  larger 
round  cells  of  a  diameter  five  or  six  times  as  great  as  that  of  a  white  blood 
corpuscle,  containing  a  hyaline  substance,  and  no  nucleus.  The  bacilli  are 
chiefly  found  in  these  large  cells.  As  the  disease  progresses  other  nodules  are 
formed,  upon  the  lips,  in  the  pharynx,  and  in  the  larynx.  Upon  the  skin 
the  nodule  is  covered  by  normal  skin,  or  the  skin  is  thinned  and  shiny.  The 
nodule  is  situated  in  the  skin,  and  moves  with  it.  They  are  to  be  differentiated 
from  other  nodules  by  their  hardness,  painlessness,  and  the  fact  that  they  show 
but  little  tendency  to  undergo  ulceration ;  in  this  they  differ  from  tubercular, 
syphilitic,  or  cancerous  nodules.  When  the  nodules  occur  in  the  larynx,  they 
may  give  rise  to  dangerous  dyspnea. 

The  Examination  of  the  Cavity  of  the  Nose. — The  examination  of  the  cavity 
of  the  nose  may  be  conducted  from  the  front  or  from  the  rear — anterior  and 
posterior  rhinoscopy. 

Anterior  Rhinoscopy. — In  order  to  examine  the  nose  from  in  front  one 
introduces  into  the  nostril  one  or  other  of  the  forms  of  nasal  speculum,  and 
illuminates  the  cavity  by  means  of  reflected  light  and  a  head  mirror,  or,  more 
conveniently,  with  an  electric  headlight.  The  speculum  should  be  inserted 
well  into  the  nose,  and  the  tip  of  the  nose  may  be  elevated  with  the  thumb  for 
the  purpose.  The  mucous  membrane  of  the  septum  of  the  nose  and  of  the 
inferior  turbinated  bone  is  thus  brought  into  view,  and  a  portion  of  the  middle 
fossa.  It  is  sometimes  possible  in  normal  cases  to  see  the  posterior  pharyngeal 
wall  in  this  way;  but  if  the  space  between  the  turbinated  bone  and  septum  is 
so  large  that  the  posterior  wall  is  visible  over  a  considerable  area,  the  patient 
is  probably  suffering  from  atrophic  rhinitis.  The  muscular  movements  of  the 
levator  of  the  soft  palate,  which  forms  a  part  of  the  outer  border  of  the  pos- 
terior opening  of  the  nose,  can  be  identified  by  asking  the  patient  to  pronounce 
the  letter  K  or  I. 

Posterior  Rhinoscopy. — Posterior  rhinoscopy  is  used  to  examine  the 
vault  of  the  pharynx,  the  orifices  of  the  Eustachian  tubes,  the  posterior  nares, 
and  the  posterior  ends  of  the  turbinated  bones.  The  examination  is  conducted 
through  the  mouth.  The  instruments  used  are  the  head  mirror,  or  electric 
light ;  a  tongue  depressor ;  a  small  laryngoscopic  mirror  on  the  end  of  a  handle, 
and  usually  circular  in  shape ;  and  sometimes  a  blunt  retractor,  which  is  used 
to  pull  forward  the  soft  palate.  In  very  nervous  or  sensitive  persons,  paint- 
ing or  spraying  the  pharynx  with  a  little  two-per-cent  cocain  solution,   five 

minutes  before  the  examination  is  conducted,  sometimes  renders  it  less  difficult. 
31 


466  INJUKIES   AND   DISEASES    OF   THE   FACE 

The  surgeon  sits  in  front  of  the  patient  with  the  mirror  upon  his  forehead, 
the  tongue  depressor  in  his  left  hand,  and  the  small  laryngoscopic  mirror  in  his 
right.  The  patient  sits  facing  the  surgeon  with  his  head  erect,  or  bent  a  little 
forward.  Before  introducing  the  laryngoscopic  mirror  it  should  be  gently 
warmed  in  the  name  of  an  alcohol  lamp  to  prevent  the  condensation  of  the 
moisture  of  the  patient's  breath  upon  the  surface  of  the  mirror.  The  patient 
is  directed  to  open  his  mouth ;  the  tongue  depressor  is  introduced  well  onto  the 
dorsum  of  the  tongue,  and  the  tongue  is  gently,  but  firmly,  depressed.  The 
small  mirror  is  then  introduced,  without  touching  the  throat,  well  behind  the 
soft  palate,  toward  the  back  of  the  pharynx.  Meantime  the  patient  is  directed 
to  breathe  naturally.  It  requires  some  practice  to  get  a  satisfactory  view. 
The  posterior  border  of  the  septum  forms  a  good  landmark  from  which  to 
judge  of  the  relative  position  of  the  structures  seen.  In  some  cases  a  small 
curved  retractor  is  passed  behind  the  soft  palate  to  draw  the  structure  forward, 
and  increase  the  space  between  it  and  the  posterior  pharyngeal  wall.  The 
patient  himself  holds  the  tongue  depressor,  or  a  self-retaining  tongue  depressor 
must  be  used.  By  slight  movements  of  the  laryngoscopic  mirror  the  different 
portions  of  the  vault  of  the  pharynx,  the  orifices  of  the  Eustachian  tubes,  and 
the  posterior  nares,  nasal  septum,  and  posterior  extremities  of  the  turbinated 
bones  are  brought  into  view. 

Much  information  in  regard  to  the  condition  of  the  upper  pharynx,  etc., 
can  be  gained  by  digital  exploration  with  the  forefinger,  introduced  through 
the  mouth  and  passed  gently  up  behind  the  soft  palate.  The  presence  of 
adenoids,  tumors,  foreign  bodies,  exposed  bone,  etc.,  may  thus  be  felt.  In 
order  to  make  the  examination  the  surgeon  stands  at  one  side  of  or  behind 
the  patient,  and  holds  his  head  quiet  with  his  left  arm  and  hand,  while  the 
right  forefinger  is  introduced  into  the  mouth.  In  order  to  avoid  the  risk  of 
being  bitten,  it  is  desirable  to  place  a  gag  between  the  patient's  back  teeth, 
and  have  it  held  by  an  assistant.  Through  the  anterior  nares  it  is  sometimes 
possible  to  introduce  a  probe  into  the  frontal  sinus,  the  antrum  of  Highmore, 
and  rarely  into  the  ethmoid  cells.  The  manipulations  are  rather  delicate, 
and  harm  may  be  done  unless  they  are  performed  with  gentleness  and  dex- 
terity. They  are  not  very  generally  attempted  by  surgeons.  (For  a  descrip- 
tion of  the  technic,  the  reader  is  referred  to  an  article  by  Prof.  W.  Kiimmel, 
of  Breslau,  in  vol.  i,  "  A  Handbook  of  Practical  Surgery,"  E.  von  Bergmann, 
etc.,  p.  785  et  seq.,  and  to  special  works  on  the  Nose  and  Throat.) 

Diseases  of  the  Cavity  of  the  Nose. — Nosebleed — Epistaxis. — Nosebleed 
occurs  from  injuries  and  diseases  of  the  nasal  mucous  membrane  and  in  the 
course  of  general  infectious  diseases;  further,  in  hemophilia,  diseases  of  the 
heart,  obstruction  to  the  portal  circulation,  cirrhosis  of  the  liver,  for  example. 
The  local  causes,  other  than  injuries,  are  ulcers  of  the  nose — simple,  tubercu- 
lar, syphilitic,  often  situated  on  the  septum — tumors  and  varicosities  of  the 
veins  of  the  inferior  turbinated  bone  or  septum.  The  bleeding  in  most  cases 
takes  place  from  the  septum  or  the  inferior  turbinated  bone  near  the  front  of 


INJUKIES   AND   DISEASES    OF   THE   NOSE  467 

the  nose ;  the  blood  escapes  through  the  anterior  nares  or  flows  backward  into  the 
pharynx.  In  case  it  is  hard  to  see  the  source  of  bleeding,  the  nose  may  be 
cleaned  by  snuffing  up  salt  and  water,  and  may  then  be  sprayed  or  painted  with 
two  to  five-per-cent  cocain  solution  or  with  1-1,000  adrenalin  solution.  If  a 
patient  is  unconscious  the  blood  may  run  down  the  pharynx  into  the  stomach, 
and  be  followed  by  hematemesis,  or  down  the  windpipe,  causing  asphyxia  or, 
later,  septic  pneumonia. 

Acute  Inflammation  of  tiie  Nasal  Membrane — Acute  Coryza. — 
Acute  coryza  occurs  as  the  result  of  exposure  to  cold  and  wet,  and  from  the 
inhalation  of  dust  and  irritating  vapors  and  gases.  It  is  attended  by  an  in- 
crease in  the  number  of  bacteria  in  the  nose.  The  symptoms  are  interference 
with  nasal  respiration — from  swelling  of  the  mucous  membrane,  loss  or  diminu- 
tion in  the  sense  of  smell  and  taste,  sometimes  frontal  headache.  The  dis- 
charge from  the  nose  is  increased ;  at  first,  watery  and  irritating  to  the  nos- 
trils, later,  muco-purulent  and  thick ;  in  severe  cases  it  may  be  brownish  red 
and  abundant,  or  blood-stained.  The  ear  and  the  accessory  cavities  of  the 
nose  may  be  involved.  (Symptoms  discussed  under  Ear,  Frontal  Sinus, 
Antrum,  etc.) 

Chronic  Nasal  Catarrh. — Chronic  nasal  catarrh  is  usually  described  as 
existing  in  two  forms,  hypertrophic  and  atrophic  rhinitis. 

Hypertrophic  Rhinitis. — Hypertrophic  rhinitis  is  attended  by  chronic  swell- 
ing and  thickening  of  the  mucous  membrane,  covering  especially  the  inferior  tur- 
binated bone,  and  is  frequently  accompanied  by  congenital  lateral  deviation  of  the 
cartilaginous  and  bony  septum  of  the  nose.  There  is  an  increased  discharge  of 
mucus,  or  muco-pus,  from  the  nose,  more  or  less  interference  with  nasal  breath- 
ing. Intercurrent  attacks  of  acute  coryza  are  common,  especially  during  the 
winter  months.  The  discharge  from  the  nose  is  not  offensive.  These  patients 
are  sometimes  subject  to  attacks  of  asthma,  to  severe  headaches,  to  neuralgia 
of  the  fifth  nerve,  to  hay  fever,  to  disturbances  of  digestion,  to  chronic  catarrhal 
inflammation  of  the  middle  ear,  with  progressive  diminution  in  the  sense  of 
hearing  and  thickening  of  the  tympanic  membrane.  The  swelling  of  the 
mucous  membrane  of  the  Eustachian  tube  prevents  the  proper  equalization  of 
air-pressure  between  the  pharynx  and  the  middle  ear.  The  patients  so  afflicted 
are  often  unable  to  inflate  the  middle  ear  at  will.  Concavity  of  the  tympanic 
membrane  can  be  observed.  The  disease  is  often  complicated  by  atrophic 
rhinitis. 

Atrophic  Rhinitis. — Atrophic  rhinitis  is  characterized  by  atrophy  of  the 
mucous  membrane  covering  the  turbinated  bones,  by  a  purulent  discharge  from 
the  nose,  by  the  formation  of  abundant  crusts  in  the  nasal  fossae,  by  putre- 
factive changes  in  the  discharge  and  in  these  crusts,  and  a  stinking  breath 
{ozena).  Anterior  rhinoscopy  permits  one  to  see  the  crusts,  the  diminution 
in  size  of  the  turbinated  bone,  and  the  increase  in  the  space  between  this 
bone  and  the  septum,  so  that  the  posterior  pharyngeal  wall  becomes  visible 
over    a    considerable    area.       Both    atrophic    and    hypertrophic    rhinitis    may 


468  INJURIES   AND   DISEASES    OF   THE   FACE 

be  complicated  by  purulent  or  catarrhal  inflammation  of  the  accessory  air 
cavities. 

Perforating  Ulcer  of  the  Septum  of  the  Nose. — As  the  result  of 
traumatisms  or  infections  an  ulcer  may  form  on  the  cartilaginous  septum  of 
the  nose,  of  a  chronic  character,  ending  in  perforation  of  the  •  septum.  The 
symptoms  are  nosebleed  and  a  purulent  discharge  from  the  nose.  The  rounded 
ulcer  is  visible  upon  inspection  through  the  anterior  nares.  The  perforation 
usually  heals,  leaving  a  circular  defect  in  the  septum. 

Gonorrhea  of  the  Nose. — Gonorrhea  of  the  nose  is  exceedingly  rare. 
The  symptoms  are  an  acute  catarrh  of  the  nose.  The  identification  of  the  gono- 
coccus  is  necessary  for  a  diagnosis. 

Diphtheria  of  the  Nasal  Mucous  Membrane. — Diphtheria  of  the  nasal 
mucous  membrane  occurs  usually  in  the  back  part  of  the  nose,  as  an  extension 
of  diphtheria  of  the  pharynx.  Infection  of  a  fissure  or  abrasion  inside  the 
nostrils,  on  the  mucous  membrane  of  the  septum,  is,  nevertheless,  possible.  Some 
years  ago  I  suffered  from  a  small  ulcer  in  this  situation,  which  became  covered 
with  a  diphtheritic  membrane,  and  would  not  heal.  It  was  followed  in  a  few 
days  by  typical  pharyngeal  diphtheria;  paralysis  of  some  of  the  muscles  of 
the  throat  followed. 

Abscess  of  the  Submucous  Tissues  of  the  Nasal  Foss.e. — Abscess  of 
the  submucous  tissues  of  the  nasal  fossae  is  rather  rare,  but  may  occur  as  the 
result  of  traumatisms  and  infections  in  the  neighborhood  of  the  nose.  The 
symptoms  and  signs  are  those  of  an  acute  inflammation  of  the  nasal  mucous 
membrane,  to  which  are  added  pain  and  sepsis.  They  are  to  be  recognized 
usually  by  direct  examination. 

Tuberculosis  of  the  Nasal  Mucous  Membrane. — Tuberculosis  of  the 
nasal  mucous  membrane  may  be  secondary  to  lupus  of  the  nose  and  face,  or 
may  complicate  tuberculosis  of  the  lungs ;  less  often  primary  tuberculosis  of  the 
nasal  mucous  membrane  occurs.  The  disease  is  characterized  by  the  forma- 
tion of  tubercular  ulcers  upon  the  septum,  the  floor  of  the  nasal  fossa,  and  the 
mucous-membrane  covering  of  the  inferior  turbinated  bone.  The  ulcers  have 
swollen  borders  irregularly  undermined.  The  base  of  the  ulcer  is  covered  in 
part  by  tuberculous  granulations,  and  in  part  by  necrotic  material.  They  are 
painful  and  sensitive,  and  bleed  readily.  Secondary  foci  of  tuberculosis  in 
the  form  of  small  nodules  of  a  pale-red  or  yellowish-white  color  may  be  seen 
in  the  vicinity  (submiliary  tubercles).  Sometimes  considerable  tumors  of 
tuberculous  granulation  tissue  are  formed.  They  may  be  as  large  as  a  pea  or 
larger.  They  tend  to  ulcerate  upon  the  surface,  but  contain  few  tubercle 
bacilli,  and  are  therefore  not  easy  to  diagnosticate,  even  under  the  mi- 
croscope. 

Syphilis  of  the  Nasal  FossiE. — Chancre  and  secondary  syphilitic  papules 
and  pustules  may  occur  in  the  interior  of  the  nose,  but  by  far  the  most  common 
lesions  are  the  tertiary,  circumscribed,  and  diffuse  gummatous  inflammations 
of  the  mucous  membrane,  periosteum,  and  bone,  already  described.     The  course 


INJURIES    AND   DISEASES    OF   THE    NOSE  469 

of  the  necrotic  process  is  exceedingly  chronic.  The  diagnosis,  as  a  rule,  quite 
plain. 

Foreign  Bodies  in  the  Nose. — The  diagnosis  of  foreign  bodies  in  the 
nose  is  usually  easy.  The  bodies  are  introduced  chiefly  by  children  and  luna- 
tics. Usually  the  surgeon  is  called  for  the  express  purpose  of  extracting  a 
body,  known  or  believed  to  have  been  inserted  into  the  nose.  Occasionally 
pieces  of  gauze  or  other  material  inserted  into  the  nose  to  stop  nosebleed  may 
be  forgotten  and  require  extraction.  If  the  foreign  body  is  in  the  front  of  the 
nose  it  may  be  discoverable  even  without  the  use  of  a  speculum.  If  it  is  in  the 
posterior  nares  a  finger  introduced  through  the  mouth  will  discover  it.  If  the 
foreign  body  has  long  remained  in  the  nose,  it  will  set  up  inflammation  or 
ulceration,  by  pressure,  and  produce  a  purulent  or  bloody  discharge.  Under 
such  circumstances  the  foreign  body  will  be  coated  with  dried  mucus,  and  may 
not  be  readily  recognized  on  inspection  of  the  nasal  cavity.  Sometimes  the 
presence  of  a  foreign  body  will  give  rise  to  the  formation  of  a  concretion,  by 
deposition  of  mucus,  and  of  earthy  salts.  The  symptoms  produced  will  be  the 
same  as  though  caused  by  ordinary  foreign  bodies,  which  have  long  remained 
in  the  nose. 

Insects  and  the  larva?,  of  insects  occasionally  gain  access  to  the  nose,  and, 
if  they  remain,  give  rise  to  irritation  and  inflammation,  sometimes  of  a  serious 
or  dangerous  character.  Many  varieties  of  living  worms,  insects,  and  maggots 
have  been  extracted  from  the  nose.  I  once  extracted  a  living  many-legged  crea- 
ture an  inch  and  a  half  in  length  from  the  nose  of  a  man  who  had  been 
eating  raw  oysters ;  he  had  taken  the  animal  into  his  mouth  with  the  oyster,  and 
it  had  crawled  up  behind  his  soft  palate  and  into  his  nose,  and  set  up  an 
irritation. 

Tumors  of  the  Nasal  Foss.e. — The  commonest  tumors  of  the  nasal  fossa? 
are  the  so-called  nasal  polypi.  They  are  localized  hypertrophies  of  the  nasal 
mucous  membrane  which  form  rounded,  sessile,  or  pedunculated  excrescences 
upon  the  mucous  membrane  of  a  dirty-pink,  bluish-gray,  or  white  color,  and 
of  soft  consistence.  They  often  undergo  cystic  degeneration,  and  may  form 
cystic  tumors  of  some  little  size,  filled  with  mucus.  Such  a  tumor  may  be 
formed  in  one  of  the  accessory  cavities  of  the  nose,  the  frontal  sinus,  or  the 
antrum,  and  grow  until  it  fills  the  cavity.  The  symptoms  produced  by  nasal 
polypi  are  those  of  chronic  catarrhal  inflammation  of  the  nose,  together  with 
obstruction  of  the  nasal  fossa?.  The  diagnosis  of  nasal  polypi  is  easy;  some- 
times a  polypus  may  be  present  in  the  nostril,  or  they  may  be  seen  by  inspect- 
ing the  interior  of  the  nose.  They  are  often  multiple,  and  may  be  present 
at  the  posterior  nares,  so  that  palpation  of  this  region  should  not  be  omitted 
in  making  the  diagnosis. 

Lipoma  of  the  interior  of  the  nose  is  one  of  the  rarest  of  tumors.  Fibroma 
and  chondroma  are  seldom  observed;  they  are  both  to  be  distinguished  from 
polypi  by  their  greater  hardness.  Osteoma  is  also  a  rare  tumor  in  the  nose, 
as  is  also  carcinoma.     Carcinoma  sometimes  follows  atrophic  rhinitis  or  syphi- 


470  INJURIES   AND   DISEASES    OF   THE   FACE 

litic  ulceration.  Sarcoma  originates  from,  the  cartilaginous  and  bony  frame- 
work of  the  nose. 

Signs  and  Symptoms. — The  signs  and  symptoms  produced  by  these  tumors, 
innocent  and  benign,  vary  greatly  in  different  cases  according  to  their  size 
and  origin  and  mode  of  growth.  The  first  symptom  noticed  by  the  patient 
is  usually  difficulty  in  breathing  through  one  side  of  the  nose.  If  the  tumor 
attains  a  large  size  it  invades  the  accessory  cavities  of  the  nose,  the  antrum, 
the  frontal  sinus,  the  ethmoidal  cells,  grows  backward  into  the  pharynx,  some- 
times into  the  orbit.  If  malignant  it  grows  into  the  mouth  and  invades  the 
cranial  cavity,  the  bones  of  the  face  are  deformed,  forced  apart,  and  destroyed, 
and  horrible  deformities  are  produced. 

Tumors  originating  on  the  septum  produce,  as  a  constant  symptom,  inter- 
ference with  breathing;  those  which  originate  in  the  front  part  of  the  nose 
tend  to  produce  a  bulging  at  the  root  of  the  nose  and  to  involve  the  orbit; 
those  starting  in  the  root  of  the  nose  tend  to  invade  the  base  of  the  skull  and 
the  brain.  Tumors  which  arise  in  the  anterior  part  of  the  ethmoid  bone  are 
quite  apt  to  involve  the  muscles  of  the  eye  and  their  nerves;  further,  to  pro- 
duce disturbances  of  vision  by  pressure  upon  the  optic  nerve.  Where  a 
malignant  tumor  of  this  region  has  invaded  the  interior  of  the  skull  it  is 
very  apt  to  cause  a  purulent  fatal  meningitis.  Further,  tumors  which  grow 
backward  may  cause  severe  neuralgic  symptoms  by  pressure  upon  the  branches 
of  the  fifth  pair  of  cranial  nerves.  Tumors  which  grow  into  the  antrum  of 
High  more  frequently  cause  purulent  inflammation  of  the  antrum  with  the 
corresponding  symptoms.  Carcinomata  are  very  apt  to  undergo  early  ulcera- 
tion and  to  bleed  freely.  Putrid  decomposition  of  the  sloughing  tumor  tissues 
is  accompanied  by  a  foul  odor  of  the  breath.  The  sarcomata,  with  the  excep- 
tion of  the  round-celled  form,  are  less  apt  to  ulcerate  and  to  bleed,  except 
when  they  project  into  the  pharynx.  At  the  time  when  the  patients  present 
themselves  for  examination  the  tumor,  if  malignant,  has  usually  attained  so 
large  a  size,  and  has  so  widely  invaded  the  surrounding  soft  parts  and  bones, 
that  it  is  impossible  to  say  whether  it  originated  in  the  nose  or  in  the  jaw  or 
in  the  antrum.  A  discussion  of  the  further  signs  and  symptoms  of  malig- 
nant tumors  of  this  region  is  continued  under  Tumors  of  the  Upper  Jaw,  and 
of  the  Antrum  of  Highmore. 

THE    JAWS 

Fractures. — Fkactdkes  of  the  Upper  Jaw. — Fractures  of  the  upper  jaw 
always  occur  from  direct  violence.  If  the  violence  is  moderate  one  or  other 
of  the  processes  is  broken  rather  than  the  body  of  the  bone.  The  direction  of 
the  line  of  fracture  is  very  varied,  according  to  the  direction  and  character 
of  the  force.  A  blow  upon  the  cheek  may  crush  the  malar  bone  into  the 
antrum.  By  a  blow  upon  the  upper  lip  a  fracture  of  the  alveolar  border 
can  be  produced.     The  nasal  process  is  frequently  broken  by  blows  upon  the 


THE   JAWS  471 

nose.  Severe  degrees  of  violence  may  separate  the  superior  maxillary  bones 
one  from  the  other.  I  have  seen  a  case  in  which  the  kick  of  a  horse  created 
a  central  fragment,  with  backward  displacement ;  the  line  of  fracture  ran 
vertically  upward,  outside  of  either  canine  tooth.  Gunshot  fractures  may 
produce  any  possible  degree  of  destruction  of  the  bone.  The  diagnosis  of 
fractures  of  the  upper  jaw  is,  in  most  cases,  entirely  easy.  A  large  part  of 
the  bone  is  open  to  direct  inspection  and  palpation.  All  the  signs  of  fracture 
are  usually  present.  In  cases  of  doubt  ecchymosis  in  the  roof  of  the  mouth 
would  suggest  the  presence  of  a  fracture.  In  severe  fractures  from  direct 
violence  and  from  gunshot  wounds,  the  internal  maxillary  artery  may  be  torn, 
with  serious  bleeding.  The  infra-orbital  nerve  may  be  injured ;  less  often  the 
facial. 

Fractures  of  the  Malar  Bone  and  of  the  Zygomatic  Process. — Frac- 
tures of  the  malar  bone  and  of  the  zygomatic  process  are  quite  rare  as  isolated 
injuries.  They  are  frequently  combined  with  fractures  of  the  upper  jaw. 
The  zygomatic  arch  is  more  commonly  broken  by  direct  violence  than  the 
body  of  the  bone.  The  deformity  is  usually  a  depression  or  flattening  of  the 
cheek,  easily  recognized  by  sight  and  by  palpation,  although  a  good  deal  of 
swelling  is  usually  present.  Mobility  and  crepitus  are  less  commonly  observed. 
Disturbances  of  sensation  in  the  nose,  cheek,  and  upper  lip,  together  with 
exophthalmos,  and  later  ecchymosis  into  the  conjunctiva,  indicate  that  the 
fracture  has  extended  into  the  floor  of  the  orbit  and  has  injured  the  infra- 
orbital nerve.  If  the  zygomatic  process  is  driven  inward,  it  may  press  against 
the  coronoid  process  of  the  lower  jaw,  and  thus  interfere  with  the  movements 
of  that  bone. 

Fractures  of  the  Lower  Jaw. — The  lower  jaw  is  broken  more  often 
than  any  other  bone  of  the  face.  The  most  frequent  cause  is  a  blow  upon  the 
chin.  Much  less  often,  a  blow  from  the  side.  Double  fractures  are  by  no 
means  rare.  The  fracture  is  rarely  comminuted  except  in  the  case  of  gunshot 
fractures.  The  coronoid  process  is  very  rarely  broken.  The  condyloid  process 
more  frequently,  and  its  fracture  is  often  associated  with  fractures  of  the 
other  bones  of  the  face. 

Fracture  of  the  Alveolar  Border. — Fracture  of  the  alveolar  border  is 
common,  as  are  also  fractures  through  the  body  of  the  jaw.  Fractures  of  the 
body  behind  the  teeth  are  rare.  In  the  fractures  in  the  horizontal  portions 
of  the  body,  the  line  of  fracture  is  usually  vertical  or  only  slightly  oblique. 
Fractures  through  the  angle  or  ascending  ramus  are  oblique  or  transverse. 
Owing  to  the  proximity  of  the  mucous  membrane  of  the  mouth  many  fractures 
of  the  lower  jaw  are  compound;  the  diagnosis  is  usually  simple;  all  the  signs 
of  fracture  are  present  in  many  cases.  In  fractures  through  the  front  part 
of  the  body,  an  irregularity  in  the  line  of  the  teeth  can  usually  be  seen  or  felt. 
In  double  fractures  with  a  central  fragment,  the  middle  part  of  the  jaw  is 
drawn  downward  by  the  muscles  attached  to  its  posterior  surface. 

Fractures  behind  the  teeth  and  of  the  ascending  ramus  are  not  so  easy  to 


472  INJURIES   AND   DISEASES    OF   THE   FACE 

discover;  deformity  may  sometimes  be  detected  with  the  finger  introduced 
into  the  mouth;  crepitation  is  less  often  present.  A  fixed  point  of  pain  and 
tenderness  and  pain  on  motion  may  be  the  most  prominent  symptoms.  Al- 
though sometimes  possible,  it  is  difficult  to  detect  these  fractures  by  means  of 
the  X-rays.  The  signs  of  fracture  of  the  condyloid  process  are  localized  pain 
and  tenderness,  pain  on  motion,  and  diminished  mobility,  sometimes  crepita- 
tion. The  entire  jaw  is  sometimes  slightly  displaced  toward  the  injured  side, 
and  the  condyloid  process  itself  can  be  felt  to  be  displaced  forward  and  may 
be  partly  dislocated  into  the  zygomatic  fossa.  In  fractures  of  both  condyloid 
processes  the  entire  jaw  may  be  displaced  backward.  Fractures  of  the  coro- 
noid  process  alone  are  caused  only  by  direct  violence  to  that  region.  Failure 
of  union  in  fractures  of  the  lower  jaw  is  exceedingly  rare. 

Dislocation  or  the  Lower  Jaw. — The  jaw  is  dislocated  forward  in  by  far 
the  largest  proportion  of  cases.  Dislocation  backward  with  fracture  of  the 
anterior  wall  of  the  auditory  canal  is  rare,  and  is  due  to  extreme  degrees  of 
violence  by  blows  upon  the  chin.  A  single  case  is  on  record  where,  following 
a  severe  blow  upon  the  chin,  the  condyle  of  the  bone  had  been  driven  into 
the  cranial  cavity,  and  finally  had  produced  a  fatal  abscess  of  the  brain.  The 
forward  dislocations  are  bilateral  in  more  than  half  the  cases.  The  dislocation 
is  usually  caused  by  muscular  action  during  the  act  of  yawning  or  vomiting, 
rarely  by  a  blow  upon  the  jaw  with  the  mouth  open  or  in  the  effort  to  force 
some  very  large  object  into  the  mouth. 

The  signs  and  symptoms  of  bilateral  dislocation  are  as  follows:  The  mouth 
is  held  open,  the  jaw  projects  forward  and  cannot  be  moved.  The  condyle 
of  the  jaw  can  be  felt  anterior  to  its  normal  place,  and  a  corresponding  depres- 
sion can  be  felt  at  the  site  of  the  glenoid  cavity.  The  cheeks  are  flattened, 
the  masseter  muscles  are  usually  tense.  The  saliva  drools  from  the  mouth. 
Speaking  and  swallowing  are  difficult.  In  unilateral  dislocations  the  articular 
process  will  be  absent  from  the  glenoid  cavity  upon  only  one  side.  The  chin 
is  displaced  a  little  toward  the  uninjured  side.  The  jaw  may  still  retain 
some  mobility.  Backward  dislocation  of  the  jaw  is  usually  accompanied  by 
fracture  of  the  anterior  wall  of  the  auditory  canal.  The  entire  jaw  is  dis- 
placed backward.  The  jaw  is  immovable.  There  is  hemorrhage  from  the 
external  ear.  The  condyle  of  the  jaw  is  absent  from  its  normal  position;  the 
mouth  is  held  partly  opened.     The  dislocation  may  be  unilateral  or  bilateral. 

The  Teeth. — Caries  of  the  teeth  gives  rise  to  the  formation  of  cavities 
and  gradual  destruction  of  the  teeth,  recognizable  upon  inspection  and  explora- 
tion of  the  affected  teeth.  The  carious  areas  may  be  covered  by  tartar,  which 
requires  removal  before  the  black  or  yellow  discoloration s  and  pits  in  the 
teeth  can  be  seen  and  felt.  The  retention  and  decomposition  of  particles  of 
food  in  the  cavities  cause  the  breath  to  be  offensive.  The  subjective  symp- 
toms vary;  there  may  be  none.  Ordinarily  exposure  of  the  dentine  causes  the 
tooth  to  become  sensitive  to  heat,  cold,  and  acids.  Sometimes  tenderness  on 
pressure  exists,  and  even  pretty  severe  toothache.     The  tenderness  may  sub- 


THE   JAWS  473 

side  from  atrophy  of  the  dentine,  and  no  further  pain  be  felt  until  the  pulp 
is  exposed ;  extreme  sensitiveness  and  pain  then  occur.  Exquisitely  sensitive 
granulations  sprout  from  the  exposed  pulp.  Granulation  tissue  of  an  inflam- 
matory origin  may  also  form  between  the  tooth  and  its  socket  in  the  jaw 
(granulomata) ;  the  tooth  will  then  be  painful,  sensitive,  and  sometimes  a 
little  loose. 

Infection  with  pus  microbes  leads  to  the  formation  of  an  abscess,  either 
at  the  root  of  the  tooth  between  the  tooth  and  the  jaw,  or  between  the  tooth 
and  the  gum,  or  to  a  purulent  pulpitis,  or  a  purulent  periostitis  of  the  alveolar 
process,  or  both.  In  the  first  instance  the  symptoms  are  a  severe  throbbing 
toothache,  swelling  of  the  gum,  sometimes  edema  of  the  face  and  fever.  The 
pain  is  of  a  throbbing,  boring  character;  is  worse  at  night.  The  tooth  becomes 
exquisitely  sensitive;  sometimes  it  is  raised  a  little  from  its  bed,  so  that  it 
projects  slightly  beyond  the  normal  line  of  the  teeth.  If  the  inflammation 
is  confined  to  the  periosteum  of  the  alveolar  process,  the  pain  will  be  less 
severe,  and  an  abscess  (parulis)  or  so-called  "  gum-boil  "  will  form  in  the 
neighborhood  of  the  tooth,  and  present  as  a  fluctuating,  tender  swelling  of 
the  gum,  and  finally  burst,  with  relief  of  the  symptoms.  A  purulent  sinus, 
or  tooth  fistula,  often  remains  and  discharges  a  little  pus  continuously  or  inter- 
mittently. The  chief  interest  to  the  surgeon  in  these  conditions  lies  in  the 
fact  that  in  neglected  or  improperly  treated  cases  severe  septic  processes  may 
occur,  involving  purulent  periostitis  and  osteitis  of  the  jaw,  sometimes  fol- 
lowed by  extensive  necrosis,  as  well  as  septicemia,  which  may  be  dangerous 
or  fatal.  An  abscess  at  the  root  of  a  canine  tooth  may  break  into  the  antrum 
and  cause  suppuration  in  that  cavity.  An  abscess  at  the  root  of  a  molar 
tooth,  with  periostitis  of  the  jaw,  is  not  infrequently  accompanied  by  some 
degree  of  immobility  of  the  jaw — inflammatory  lockjaw,  in  other  words. 
Tumors  connected  with  the  development  of  the  teeth  have  been  described  in 
the  chapter  on  Tumors. 

Inflammation  of  the  Gums  (Gingivitis). — The  causes  of  gingivitis  are 
want  of  cleanliness  and  the  accumulation  of  tartar  at  the  necks  of  the  teeth 
between  the  teeth  and  the  gums.  The  gums  are  somewhat  retracted,  a  little 
swollen  and  tender;  there  may  be  a  moderate  purulent  discharge  from  the 
border  of  the  gums;  the  breath  may  be  fetid.  The  presence  of  accumulated 
tartar  is  evident  on  inspection. 

Chronic  Pyorrhea  Alveolaris  (Riggs's  Disease). — Chronic  suppurative 
inflammation  of  the  gum,  at  its  junction  with  the  neck  of  the  tooth,  gradu- 
ally extending  between  the  tooth  and  the  alveolar  process,  with  atrophy  of 
the  bone,  is  a  disease  rare  in  young  adults;  it  occurs  more  often  during  middle 
life.  Its  origin  is  obscure.  Depressed  states  of  health  favor  its  occurrence — 
tabes,  malarial  poisoning,  gout,  etc.  It  may  affect  but  one  tooth,  or  several, 
or  nearly  all  the  teeth  in  succession.  The  symptoms  are  characteristic.  The 
gum  is  swollen,  retracted  from  the  neck  of  the  tooth.  There  is  usually,  not 
always,  a  purulent  discharge  from  between  the  tooth  and  the  gum.     There 


474 


INJUKIES   AND   DISEASES    OF   THE   EACE 


is  often  some  pain,  notably  upon  the  exposure  to  cold,  and  after  taking  hot 
or  cold  or  acid  liquids  into  the  mouth.  The  progress  of  the  disease  is  con- 
tinuous but  slow;  gradually  the  gum  retracts  more  and  more  from  the  tooth, 
atrophy  of  the  alveolar  socket  follows,  the  tooth  becomes  finally  loosened  in 
its  bed,  and  is  lost,  often  without  any  signs  of  disease  of  the  tooth  itself. 

Gingivitis  from  Other  Causes. — Other  causes  of  gingivitis,  sometimes 
of  an  ulcerative  character,  are  poisoning  by  lead  and  mercury,  and  scurvy. 

Lead  Poisoning. — Poisoning  by  lead  occurs,  notably  among  house  painters, 
from  neglect  of  proper  precautions.  The  gums  are  swollen,  tender,  and  red; 
there  is  a  purulent  discharge.  Along  the  edge  of  the  gums  there  is  a  distinct 
blue  or  gray  line  of  discoloration;  the  breath  is  often  fetid.  Lead  palsies, 
notably  "  drop  wrist "  {musculo-spiral  paralysis),  anemia,  colics,  and  other 
signs,  are  usually  present. 

Mercurial  Poisoning. — In  mild  cases  the  gums  are  moderately  swollen, 
tender  and  spongy,  and  bleed  easily;  slight  tenderness  is  felt  upon  sharply 
closing  the  teeth;  there  is  slight  salivation;  often  diarrhea.  In  severe  cases 
the  inflammation  may  proceed  to  ulceration.  There  is  profuse  salivation,  the 
entire  mucous  membrane  of  the  mouth  is  swollen,  the  breath  is  fetid,  anemia 
and  diarrhea  or  dysentery  are  usually  present.  There  is  retraction  of  the 
gums  from  the  teeth  during  recovery,  and  this  retraction,  if  the  poisoning 

was  severe  or  long  continued,  is  permanent. 
Scurvy. — The  gums  are  swollen  and 
spongy ;  there  is  a  purulent  discharge ; 
bleeding  from  the  gums  is  the  rule.  The 
teeth  may  be  lost.  There  are  subcutaneous 
hemorrhages  elsewhere  on  the  body,  notably 
in  the  legs,  sometimes  ulcerations.  There 
is  a  history  of  improper  feeding.  Scurvy  is 
not  uncommon  among  children  as  the  result 
of  an  exclusive  diet  of  milk  sterilized  by 
heat. 

Acute  Suppurative  Periostitis  and 
Osteitis  of  the  Jaws. — Acute  suppura- 
tive periostitis  follows  infection .  through  a^ 
diseased  tooth  more  often  than  any  other 
cause.  Injuries,  such  as  wounds  and  frac- 
tures, may  be  followed  by  a  similar  condi- 
tion. The  symptoms  are  localized  pain,  ten- 
derness, and  swelling;  more  or  less  marked 
sepsis ;  lockjaw  is  present  or  absent,  accord- 
ing to  location.  Usually  an  abscess  follows  in  the  soft  parts,  which  may  point 
externally  upon  the  face  or  in  the  mouth ;  fetor  ex  ore  is  common.  A  severe 
form  of  purulent  periostitis  and  osteitis  occurs  in  the  jaws  of  children  during 
acute  infectious  diseases,  especially  the  exanthemata,  notably  when  the  mouth 


Fig.  172. — Periostitis  of  the  Lower  Jaw 
with  Abscess  of  the  Cheek.  Infec- 
tion from  a  carious  tooth.  (New  York 
Hospital,  Out-Patient  Department.) 


THE   JAWS  475 

is  not  kept  clean.  The  general  symptoms  are  severe,  and  the  local  lesion 
often  extensive.  The  diagnosis  is  readily  made  from  the  local  signs  and  symp- 
toms.    A  purulent  discharge  from  the  tooth  sockets  is  often  present. 

Syphilitic  Gummatous  Osteitis  and  Periostitis  of  the  Jaws. — Syphilitic  gum- 
matous osteitis  and  periostitis  of  the  jaws  are  less  common  than  similar  affec- 
tions of  the  nasal  septum  and  hard  palate;  the  affection  is  exceedingly  chronic 
and  tedious.  I  recently  saw  a  young  man  with  syphilitic  necrosis  of  the 
central  portion  of  the  superior  maxilla.  The  upper  lip  was  perforated  and 
nearly  destroyed,  the  nasal  septum  was  gone.  The  area  of  necrosis  in  the 
jaw  involved  the  entire  thickness  of  the  alveolar  border,  and  included  the 
hard  palate.  The  sequestrum  of  the  jaw  measured  two  inches  and  a  half 
from  side  to  side.  The  odor  was  overpowering.  The  patient  felt  very  well 
and  had  no  pain. 

Tuberculosis  of  the  Jaws. — Tuberculosis  of  the  jaws  is  relatively  infrequent. 
Infection  may  be  primary  in  the  bone,  or  secondary  to  tuberculous  ulcera- 
tion in  the  mouth.  Usually  the  area  of  bone  affected  is  not  large.  Here,  as 
elsewhere,  the  disease  is  characterized  by  its  chronic  course;  perforation  of 
the  bone  and  periosteum;  the  formation  of  a  cold  abscess.  Incision  reveals 
a  focus  of  tuberculous  caries,  usually  of  moderate  size;  the  bone  is  softened 
and  friable.  A  tuberculous  sinus  usually  remains  unless  the  focus  is  removed 
by  operation.  The  commonest  situation  is  the  superior  maxillary  bone  at  the 
lower  border  of  the  orbit.  A  sinus,  surrounded  by  a  puckered  cicatrix,  remains 
after  spontaneous  evacuation  or  incomplete  operation. 

Actinomycosis  of  the  Jaws. — Primary  actinomycosis  of  the  jaw,  although 
very  common  in  cattle,  appears  to  be  exceptional  in  man.  The  invasion  of 
the  bone  is  usually  secondary  to  disease  of  the  soft  parts.  Undoubted  cases 
of  infection  of  the  jaw  through  a  carious  tooth  have,  however,  been  reported, 
the  fungi  having  been  demonstrated  in  the  tooth  cavity.  In  many  cases  the 
disease  begins  in  the  neighborhood  of  a  tooth,  often  carious,  either  in  the 
gum  or  in  the  periosteum  of  the  alveolar  border,  and  forms  a  slowly  increas- 
ing swelling  ending  in  an  abscess.  The  course  is  notably  slower  than  in  ordi- 
nary acute  abscess.  In  other  cases  a  slowly  progressive  infiltration  of  the 
cheek  is  observed.  The  swelling  is  at  first  rather  soft,  later  becomes  extremely 
hard,  and  finally  breaks  down,  forming  an  abscess.  The  progress  is  usually 
quite  slow  and  chronic.  The  micro-organisms  can  be  identified  in  the  discharge, 
in  scrapings,  in  the  tissues,  and  by  cultures.  Mixed  infections  are  common 
after  the  lesion  is  open.  In  a  case  of  my  own  (a  young  girl)  a  diagnosis 
of  a  chronic  periostitis  of  the  lower  jaw  with  abscess  of  the  lower  part  of 
the  cheek  was  made.  Upon  opening  the  abscess  the  presence  of  numerous 
yellowish-white  granules  in  the  pus  directed  attention  to  the  correct  diagnosis. 
Infection  had  occurred  through  the  gum.  A  small  superficial  area,  only,  of 
bone  was  involved.      (See  Actinomycosis.) 

Phosphorous  Necrosis. — Phosphorous  necrosis,  usually  of  the  lower,  rarely  of 
the  upper,  jaw,  was  formerly  a  common  condition  among  makers  of  phos- 


476  INJURIES   AND   DISEASES   OF   THE   EACE 

phorus  matches.  At  present  it  is  exceedingly  rare  in  America.  The 
phosphorus  fumes  entering  into  the  cavities  of  carious  teeth  cause  a  productive 
periostitis  with  the  formation  of  osteophytes  and  thickening  of  the  bone. 
Later,  or  in  some  cases  primarily,  purulent  inflammation  of  the  bone  and 
periosteum,  with  sometimes  total  necrosis  of  the  jaw,  follow.  The  history, 
the  pain,  swelling,  and  discharge  of  pus  from  the  emptied  tooth  sockets 
render  the  diagnosis  easy. 

Diseases  of  the  Antrum  of  Highmore. — Hydrops  of  the  Antrum. — Hydrops 
of  the  antrum  occurs  from  stoppage  of  its  outlet  into  the  nose  and  from  cystic 
degeneration  of  polypoid  growths  of  the  antrum,  or  from  cysts  developed  in 
connection  with  the  teeth  in  the  wall  of  the  antrum,  which  subsequently 
enlarge  and  occupy  that  cavity.  The  symptoms  are  chiefly  those  produced  by 
pressure.  The  anterior  wall  of  the  antrum  is  thinned  and  protrudes  as  a 
bony  or  parchmentlike  swelling,  palpable  within  the  mouth  above  the  reflec- 
tion of  the  mucous  membrane  from  the  alveolar  process  to  the  upper  lip.  A 
similar  condition  may  exist  in  the  hard  palate.  The  presence  of  a  carious 
canine  tooth  points  to  an  infectious  origin.  In  the  pure  cases  of  hydrops 
or  mucous  cyst  an  aspirating  needle  introduced  through  the  anterior  wall 
of  the  antrum  withdraws  clear,  thin  fluid  or  mucus. 

Empyema  of  the  Antrum. — Empyema  of  the  antrum  occurs  from  infec- 
tion through  a  carious  tooth  as  the  result  of  infected  fractures  and  stab 
wounds  involving  the  antrum,  from  the  presence  of  foreign  bodies  in  the 
antrum  (bullets,  portions  of  a  knife  blade,  etc.),  and  lastly  as  a  complication 
of  malignant  tumors  of  the  upper  jaw,  the  nasal  fossa?,  and  the  orbit.  The 
symptoms  are  various,  according  to  conditions;  when  due  to  infection  from 
a  tooth,  the  withdrawal  of  the  tooth  will  be  followed  by  a  continuous  or 
intermittent  discharge  of  pus  in  considerable  quantity  from  the  tooth  cavity. 
If  the  outlet  into  the  nose  remains  open,  pus  will  be  discharged  from  the  nose 
— notably  when  the  patient  lies  upon  the  sound  side.  If  the  outlet  becomes 
closed,  accumulation  of  pus  will  lead  to  distention  of  the  antrum.  Symptoms 
of  septic  absorption,  together  with  pain  and  tenderness  over  the  antrum  and 
swelling  of  the  face,  will  follow.  If  the  anterior  wall  is  perforated,  an  abscess 
or  a  septic  cellulitis  of  the  face  with  grave  symptoms  of  sepsis,  or  pyemia  and 
death,  may  result. 

The  diagnostic  signs  and  symptoms,  other  than  the  above,  are  a  unilateral 
discharge  of  pus  from  the  nose,  sometimes  having  a  fetid  odor,  which  the 
patient  is  able  to  detect,  thus  differing  from  ozena  and  syphilis.  In  some  cases 
the  surgeon  may  be  able  to  see  pus  coming  from  the  middle  meatus  of  the  nose 
by  anterior  rhinoscopy  with  the  head  tipped  back.  In  others,  transillumination 
of  the  sinus  by  an  electric  light  held  in  the  mouth  is  useful.  If  the  antrum 
is  filled  with  pus  it  may  appear  to  be  more  opaque  than  the  antrum  of  the 
sound  side,  not  a  very  definite  sign  in  many  cases.  The  examination  must 
be  conducted  in  an  entirely  dark  room.  The  patient  takes  a  small  electric 
light  into  his  mouth  and  closes  his  lips.     Upon  illumination  of  the  lamp,  that 


THE   JAWS  477 

side  of  the  face  and  pupil  of  the  eye  will,  in  some  instances  if  the  antrum  is 
filled  with  pus,  appear  dark  or  less  brightly  illuminated  than  the  sound 
side. 

The  Tumors  of  the  Antrum  of  Higiimore. — The  most  common  tumor 
is  the  soft  polypus,  such  as  occurs  in  the  nose.  It  will  give  rise  to  no  symp- 
toms unless  it  happens  to  occlude  the  passage  into  the  nose  or  undergo  cystic 
degeneration,  as  already  described.  Other  tumors,  such  as  carcinoma,  sar- 
coma, enchondroma,  and  myxoma  occasionally  occur  in  the  antrum.  They 
give  rise  to  symptoms  only  when  they  have  reached  such  a  size  that  they 
fill  and  distend  the  cavity. 

Tumors  of  the  Jaws.— Tumors  may  affect  the  alveolar  processes  of  the 
jaws  or  the  bodies  of  the  jaws.  A  general  term,  long  in  use  to  indicate  tumors 
arising  from  or  upon  the  gums,  is  epulis.  Among  them  are  small  fibromata 
which  may  develop  upon  the  gums,  usually  of  children.  They  are  generally 
hard,  insensitive  tumors  of  a  red  or  bluish-red  color,  of  slow  growth.  Com- 
bination forms,  with  sarcoma,  are  exceedingly  common. 

Granuloma. — After  the  extraction  of  teeth  in  children,  and  from  the  cavi- 
ties in  carious  teeth  which  expose  the  pulp,  and  after  fractures  of  the  teeth 
with  exposure  of  the  pulp,  there  sometimes  sprout  little  masses  of  granulation 
tissue  which,  after  a  time,  may  become  fairly  firm  and  insensitive.  Similar 
tumors  may  grow  from  the  margin  of  a  sinus  leading  to  the  root  of  a  decayed 
tooth.  They  are  usually  bright  red  or  pink  in  color,  and  of  an  uneven,  granu- 
lar surface.  Their  appearance  and  origin  establishes  the  diagnosis.  The 
fibro-sarcomata  frequently  occur  upon  the  alveolar  border  of  the  jaws.  They 
may  originate  from  the  gum,  or  from  the  periosteum,  or  from  the  medulla 
of  the  bone.  Those  which  originate  from  the  periosteum  and  the  gum  are 
firm  and  elastic,  rounded  or  flattened,  sessile  or  pedunculated  tumors,  of  mod- 
erate size,  containing  giant  cells,  and  often  of  slight  malignancy.  When  they 
originate  in  the  medulla  of  the  bone  they  cause  enlargement  of  the  bone 
and  its  final  perforation  by  absorption.  They  are  usually  tumors  of  rather 
slow  growth.  Such  tumors  may  originate  in  the  wall  of  the  antrum,  and 
after  filling  that  cavity  may  cause  distention  and  perforation  with  pressure 
symptoms  and  deformity. 

Odontoma. — The  tumors  arising  from  tooth  germs  have  already  been  fully 
described  under  Tumors. 

Enchondroma  and  osteoma,  when  they  grow  from  the  alveolar  border,  are 
to  be  recognized  by  their  slow  growth,  by  their  hardness  and  absence  of  the 
signs  of  malignancy.  They  may  produce  severe  pain  from  pressure  upon 
nerve  trunks.  The  various  forms  of  sarcoma  may  arise  from  the  alveolar 
processes  of  the  jaw;  the  most  common  among  them  are  the  giant-celled  sar- 
comata. The  more  malignant  forms  may  also  occur,  but  more  commonly 
originate  in  the  body  of  the  jaw. 

Carcinoma  originates  from  the  pavement  epithelium  of  the  gums.  The 
first  symptoms  noticed  by  the  patient  may  be  lossening  of  one  or  more  teeth. 


478 


INJURIES   AND   DISEASES    OF   THE   FACE 


The  gum  in  the  neighborhood  will  be  thickened  and  swollen,  and  will  soon 
ulcerate;  a  bloody,  purulent  discharge  is  then  present.  Putrefactive  changes 
occur,  and  the  breath  acquires  a  fetid  odor.  The  loosened  teeth  fall  out. 
The  ulcerative  process  extends  and  is  sometimes  accompanied  by  papillary 
outgrowths  somewhat  resembling  a  cockscomb.  The  bone  is  soon  invaded 
and  destroyed,  and  the  subsequent  progress  of  the  disease  is  from  bad  to 
worse,  as  is  the  case  with  carcinoma  elsewhere.  The  cancers  originating  from 
flat  epithelium  are  typical  epitheliomata.  The  disease  occurs  in  elderly  persons, 
and  its  rapid  progress  soon  makes  the  diagnosis  clear.  In  case  of  doubt  a  bit 
of  tissue  may  be  removed  for  microscopical  examination. 

Tumors  of  the  Bodies  of  the  Jaws. — The  tumors  of  the  bodies  of  the 
jaws  belong,  for  the  most  part,  to  the  connective-tissue  group.  The  benign 
forms  are  the  fibroma,  enchondroma,  and  osteoma.  The  fibromata  cause,  as 
already  stated,  enlargement  and  final  perforation  of  the  bone.     In  some  cases 

the  periosteum  remains  intact  and 
continues  to  produce  a  thin  layer 
of  new  bone  around  the  tumor  un- 
til the  bone  may  be  dilated  to  a 
large  size.  Although  these  tumors 
are  benign  and  of  slow  growth,  they 
may  reach  a  very  large  size  and 
produce  extraordinary  and  hideous 
deformities.  They  are  generally 
hard  or  firm  tumors,  show  no  ten- 
dency to  infiltrate  the  surrounding 
parts,  nor  are  they  apt  to  undergo 
ulceration  unless  they  are  exposed 
to  irritation  in  the  interior  of  the 
mouth,  pharynx,  or  nose ;  such  ul- 
ceration as  occurs  is  usually  super- 
ficial. Their  symptoms  are  caused 
chiefly  by  pressure,  deformity,  and 
mechanical  interference  with  func- 
tion. Combinations  with  osteoma, 
enchondroma,  myxoma,  and  sar- 
coma are  common.  Sarcomatous 
degeneration  may  also  occur  in  a 
fibrous  tumor;  it  will  then  acquire 
the  characters  of  a  malignant  growth.  The  enchondromata  occur  in  young 
persons,  usually  from  the  periosteum  rather  than  the  medulla.  As  a  pure 
form  of  tumor  they  are  extremely  rare,  but  are  fairly  common  in  combina- 
tion with  fibroma,  myxoma,  and  osteoma.  Like  the  fibromata,  they  may 
grow  to  a  large  size,  invade  the  various  cavities  of  the  face,  cause  absorp- 
tion  and    dilatation   of  bone,    and   remarkable    deformities.      The   history   of 


Fig.  173. — Enormous  Mixed  Tumor  Growing  from 
the  Body  of  the  Lower  Jaw  of  a  Generally 
Benign  Character.  (Collection  of  Dr.  Charles 
McBurney.) 


THE   JAWS 


479 


their  growth  resembles  that  of  fibroma.  They  are,  of  course,  hard  tumors. 
The  general  health  is  not  affected.  Osteoma  may  occur  as  a  circumscribed  or 
more  diffuse  growth  from  any  portion  of  the  jaws.  They  frequently  result 
from  ossification  of  an  enchondroma.  They  are  hard  tumors  of  slow  growth 
and  benign  characteristics,  though  they  may  attain  great  size.  They  are 
sometimes  multiple. 

Leontiasis  Ossium. — Diffuse  production  of  new  bone  in  connection  with 
the  jaws,  the  other  bones  of  the  face,  and  the  cranium,  occurs  as  a  rare  disease 
to  which  the  name  leontiasis  has  been  given.  The  entire  skull  may  be  so  in- 
creased in  thickness  that  the  dried  skull  may  weigh  four  or  five  times  as  much 
as  it  should.  In  the  few  cases  reported  the  disease  has  developed  in  early  life, 
and  has  extended  over  a  period  of  many  years.  One  of  the  bones  of  the  face 
is  usually  affected,  and  as  time  goes  on  one  bone  after  another  becomes  en- 
larged, thickened,  with  a  development  of  prominent  bony  masses  here  and  there. 
A  slowly  progressive  interference  with  the  function  of  organ  after  organ,  and 
cavity  after  cavity,  takes  place  by 
pressure,  until  the  patient's  death. 

Sarcomata. — Sarcoma  is  the 
most  frequent  form  of  tumor  af- 
fecting the  jaws.  It  may  occur 
alone  or  in  combination  with  the 
benign  forms — fibroma,  chondro- 
ma, osteoma — often  as  a  degener- 
ative change  in  the  latter.  All 
varieties  of  sarcoma  develop  in  the 
jaws — round,  spindle,  giant,  and 
mixed-celled  forms.  The  round- 
celled  sarcoma  is  the  most  malig- 
nant type,  and  may  destroy  life 
very  rapidly.  The  sarcomata  may 
grow  from  the  periosteum,  the  sub- 
stance of  the  bone,  or  may  be  pri- 
mary in  the  soft  parts,  and  involve 
the  bone  secondarily.  The  sarcom- 
ata of  the  jaws  show  a  common 
tendency  to  grow  rapidly,  to  infil- 
trate and  destroy  the  bones  and 
soft  parts,  to  produce  rapidly  pro- 
gressive deformity,  to  invade  the 
cavities  of  the  face  and  the  skull, 
to  undergo  degenerative  changes,  to  ulcerate  and  bleed  when  they  reach  the 
surface  of  the  mucous  membrane,  and  to  destroy  life.  Death  occurs  from 
repeated  hemorrhages,  from  sepsis,  pneumonia,  from  invasion  of  the  interior 
of  the  skull,  and  from  exhaustion. 


Fig.  174. — Giant-Celled  Sarcoma  of  the  Upper 
Jaw.  (Kindness  of  Dr.  W.  S.  Halsted,  of  Balti- 
more.) 


480 


INJURIES    AND    DISEASES    OF    THE   FACE 


C-ABcmoMA  of  the  Jaws. — Carcinoma  of  the  jaws  occurs,  for  the  most 
part,  secondary  to  carcinoma  of  the  glandular  organs,  or  to  epithelioma  of  the 
skin,  or  of  the  mucous  membrane  of  the  mouth,  the  tongue,  the  nose,  or  its 
accessory  cavities.  The  tumors  rapidly  infiltrate  and  destroy  the  bone ;  soon 
grow  beyond  the  reach  of  operative  interference,  and  destroy  life  in  one  of  the 

ways  already  indicated  as  peculiar 
to  malignant  tumors.  The  carci- 
nomata  are  apt  to  undergo  early 
ulceration  with  putrefactive  changes, 
to  bleed,  and  to  produce  intoxica- 
tion by  the  absorption  of  putrid 
and  septic  products. 

Diagnosis  of  Malignant  Tu- 
mors of  the  Jaws. — In  regard  to 
the  diagnosis  of  the  malignant  tu- 
mors of  the  jaws,  it  may  be  said 
that  sarcomata  occur  for  the  most 
part  in  young  people,  or  before 
middle  age;  carcinoma,  on  the 
other  hand,  is  developed  in  ad- 
vanced life.  Sarcoma  is  not  in- 
frequently associated  with  trau- 
matism and,  in  a  good  many  in- 
stances, with  extensive  caries  of 
the  teeth  and  inflammatory  condi- 
tions of  the  gums.  The  sarcomata 
of  the  alveolar  processes  are  more 
frequent  than  those  of  the  body  of 
the  jaw. 

Fig.   175.  — Front  View  of  the  Preceding  Case  Clinically,     the     Sarcomata     may 

of  Giant-Celled  Sarcoma  of  the   Upper  Jaw.  "  '                                                  J 

The  patient  had   observed   the  presence  of  the  be    hard    Or    Sof t ;    the    majority    of 

tumor  for  several  vears.      She  was  a  negress  aged  -i               i         i       •           j*                i 

about  fiftv  vears.  '  Operative  removal  of  both  su-  tllOSe     developing     irom     the     periOS- 

Z  thourf"  "'"  foU°wed  by  death  fr°m  shock      teum  are  fairly  hard  tumors.    Those 

growing  from  the  medulla  are  apt 
to  be  softer  and  more  malignant.  Cystic  degeneration  and  hemorrhages 
into  the  substance  of  the  tumor  are  more  common  in  the  softer  forms. 
The  cystic  cavities  contain  bloody,  or  brown,  serous  fluid,  or  gelatinous  and 
crumbly  masses  of  a  dirty-brown  color.  The  central  sarcomata,  at  first,  dilate 
the  bone,  then  perforate  it;  rapidly  invade  the  cavities  of  the  face,  notably  the 
mouth,  the  antrum,  and  the  nasal  cavity;  sometimes  penetrate  the  skin,  ulcer- 
ate, and  form  f ungating  bleeding  masses.  In  the  upper  jaw  the  early  symp- 
toms may  be  those  of  suppuration  of  the  antrum — a  frequent  complication  of 
malignant  tumors  in  this  region.  The  central  growths  cannot  always  be  rec- 
ognized at  a  single  examination,  during  the  early  stage  of  their  development, 


THE   JAWS 


481 


before  they  have  broken  through  the  bony  capsule.  The  perforation  of  the 
jaw,  and  even  the  formation  of  a  distinct  enlargement,  is  usually  preceded  by 
continuous  dull  pain.  On  the  lower  jaw  they  form  rounded  tumors  of  a  vari- 
able size ;  small  at  first,  later  sometimes  as  large  as  a  child's  head.  In  the 
upper  jaw,  in  addition  to  the  deformity,  there  is  early  interference  with  nasal 
breathing,  parchmentlike  thinning  of  the  bone  in  accessible  situations,  with 
crackling  on  palpation.  Later,  softening,  with  pitting  on  pressure.  Secondary 
involvement  of  lymph  nodes  is  the  exception  rather  than  the  rule. 

Further,  it  may  be  said  that  the  prognosis  of  the  harder  forms,  growing 
from  the  periosteum,  is  much  better  than  is  the  case  with  those  developing 
from  the  cancellous  tissue  of  the  bone  itself.  The  carcinomata  of  the  jaw 
occur,  as  stated,  for  the  most  part,  as  secondary  tumors  following  cancer  of 
the  lip,  the  tongue,  the  floor  of  the  mouth,  the  gums,  the  parotid  and  submax- 
illary glands,  etc.  Occasionally  they  have  their  origin  in  displaced  epithelial 
germs  in  the  bone  itself.  They  are  tumors  of  advanced  life,  and  occur  much 
more  frequently  in  the  upper  than  in  the  lower  jaw.  As  already  stated,  it  is 
usually  impossible  to  say,  in  the  given  case,  whether  the  tumor  originated  in 
the  mucous  membrane  of  the  nose  or  antrum,  or  in  the  bone  itself. 

The  symptoms  are  pain,  referred  to  the  teeth,  sometimes  radiating  into 
different  parts  of  the  head  or  face;  or  a  dull  pain,  referred  broadly  to  one  side 
of  the  face.  In  the  upper  jaw  interfer- 
ence with  nasal  breathing  is  an  early  symp- 
tom. Inspection  through  the  nose,  or  pal- 
pation in  the  throat,  may  discover  one  or 
other  side  of  the  nose  more  or  less  com- 
pletely filled  with  soft,  bleeding  masses  of 
tumor  tissue.  The  teeth  become  loosened 
and  leave  carcinomatous  ulcerations  be- 
hind. There  follow  swelling  and  infiltra- 
tion of  the  soft  tissues  of  the  face.  As  the 
tumor  approaches  the  surface  the  skin  be- 
comes infiltrated,  immovable,  hardened,  and 
reddened.  Perforation  of  the  skin  and  ul- 
ceration occurs  relatively  late  in  the  dis- 
ease, if  at  all.  Invasion  of  the  orbit  causes 
exophthalmos,  disturbances  of  vision  and 
blindness.  In  the  lower  jaw  involvement 
of  the  submaxillary  lymph  nodes  is  early 
noticeable.  The  destructive  process  in  the 
bone  is  so  rapid,  ulceration  and  pyogenic 
infection  occur  so  early,  together  with 
toothache,  loss  of  teeth,  and  suppuration,  that  the  tumor  may  be  mistaken 
for  periostitis,  or  osteitis  of  the  jaw  with  abscess.  In  fact,  necrosis  of  a 
considerable  mass  of  bone  is  not  very  rare  as  the  result  of  rapid  degenera- 
32 


Fig.  176. —  Tuberculous  Osteomyelitis 
of  the  Lower  Jaw  in  a  Boy.  The 
child  also  suffered  from  a  tuberculous 
elbow,  tuberculous  ribs  and  empyema. 
(Case  of  Dr.  Charles  N.  Dowd,  St. 
Mary's  Hospital.) 


482  INJUKIES   AND   DISEASES    OF   THE   FACE 

tire  clianges  in  the  tumor.  The  prognosis  of  carcinoma  of  the  jaw  is  the 
worst  possible. 

Diseases  of  the  Temporo-maxillary  Articulation. — Acute  Synovitis. — Acute 
synovitis  of  the  temporo-maxillary  joint  may  occur  as  the  result  of  acute  rheu- 
matism ;  in  the  course  of  acute,  infectious  diseases ;  as  acute  gonorrheal  syno- 
vitis. The  diagnosis  is  made  by  the  recognition  of  pain,  swelling,  and  dimin- 
ished mobility,  or  pain  on  motion,  in  the  joint,  together  with  the  concomitant 
rheumatic  affections  of  other  joints,  the  presence  of  gonorrhea,  measles,  scarla- 
tina, etc. 

Inflammatory  Closure  of  the  Jaws. — There  is  complete,  or  incomplete, 
immobility  of  the  temporo-maxillary  joint  when  acute  inflammatory  processes 
exist  in  the  neighborhood — mumps,  abscesses  in  the  region  of  the  lower  molars, 
acute  suppurative  tonsillitis,  pretonsillar  abscess,   etc. 

Tuberculosis. — Tuberculosis  of  the  joint  is  rare,  and  is  usually  secondary 
to  tuberculosis  of  the  temporal  bone.  The  signs  are  those  of  tuberculosis  of 
joints,  a  chronic  course,  pain  on  motion,  the  formation  of  sinuses,  a  sequestrum, 
etc.     Ankylosis  is  an  uncommon  result. 

Arthritis  deformans. — Arthritis  deformans  of  the  joint  is  rare ;  it  is 
attended  by  fibrous  degeneration  of  the  cartilage ;  by  the  formation  of  osteo- 
phytes, absorption  of  bone,  relaxation  of  the  ligaments  with  complete,  or  partial, 
habitual  dislocation  of  the  joint,  or  by  fibrous  or  bony  ankylosis  with  inability 
to  open  the  mouth. 

Causes  of  Locked  Jaws. — Inability  to  open  the  mouth  may  proceed  from 
general  conditions  affecting  the  muscles  and  the  nerves,  such  as  tetanus.  From 
spasm  of  the  muscles  due  to  irritation  of  the  fifth  pair  of  cranial  nerves,  espe- 
cially the  third  branch,  to  injuries  or  diseases  of  the  soft  parts  or  bones  in  the 
vicinity  of  the  joint ;  and,  finally,  to  affections  of  the  joint  itself.  Some  of  the 
causes  have  already  been  mentioned ;  they  may  be  enumerated  as  follows : 
Inflammations  connected  with  the  back  teeth  and  the  jaw,  such  as  abscess, 
periostitis,  the  irritation  produced  by  molar  teeth  about  to  penetrate  the  gum, 
abscesses  and  phlegmonous  inflammations  of  the  salivary  glands,  abscesses  in 
the  throat,  in  the  soft  parts  of  the  cheek  and  the  upper  part  of  the  neck ;  as 
the  result  of  central  nervous  causes — i.  e.,  hysteria ;  from  cicatricial  contrac- 
tion following  injury  or  disease  of  the  cheeks,  parotid,  or  temporal  regions, 
notably  after  gangrene  of  the  face  (noma)  ;  following  fractures  of  the  jaw, 
with  deformity,  or  bony  ankylosis  between  the  jaw  and  the  zygomatic  process. 
Finally,  as  a  congenital  malformation  with  an  abnormal  development  of  the 
coronoid  process,  such  that  mechanical  interference  with  motion  exists.  This 
deformity  is  combined  with  arrest  of  development,  and  abnormal  smallness  of 
the  lower  jaw.  The  diagnosis  depends  upon  a  search  for  the  cause  of  the 
immobility. 


CHAPTER    XVI 

INJURIES  AND   DISEASES   OF  THE   MOUTH   AND  THROAT 

DISEASES    OF    THE    MUCOUS    MEMBRANE    OF    THE    MOUTH 

Catarrhal  Stomatitis. — Under  the  head  of  Bacteriology  of  the  Mouth  it 
was  pointed  out  that  the  mouth  was  the  home,  under  normal  conditions,  of  a 
great  variety  of  bacteria,  pathogenic  and  nonpathogenic.  Stomatitis  occurs 
as  the  result  of  mechanical,  thermal,  and  chemical  irritations.  Further,  in  the 
absence  of  proper  cleanliness,  one  or  other  variety  of  bacteria  may  cause  inflam- 
mation of  the  mucous  membrane  of  the  mouth  of  any  grade  of  severity.  A 
catarrhal  inflammation,  slight  or  severe,  ulceration,  or,  under  favorable  condi- 
tions, gangrene. 

Catarrhal  Inflammation. — Catarrhal  inflammation  is  characterized  by  red- 
ness, tenderness,  and  swelling  of  the  mucous  membrane ;  by  desquamation  of 
the  epithelium  ;  by  an  increased  secretion  of  mucus,  containing  a  greater  or  less 
proportion  of  leucocytes.  There  may  be  small  erosions  and  superficial  ulcer- 
ations. 

Ulcerative  Stomatitis. — Ulcerative  stomatitis  occurs  in  conditions  of  general 
depression,  in  the  course  of  acute  infectious  disease,  as  the  result  of  poisoning 
by  mercury  and  lead  (as  already  described  under  affections  of  the  gums),  in 
scurvy.  All  the  forms  of  ulcerative  stomatitis  occur  most  often,  and  are  of 
the  greatest  intensity,  among  those  who  have  neglected  the  due  precautions 
of  cleanliness — cleaning  the  teeth,  the  use  of  mouth  washes,  periodic  visits  to 
a  dentist,  etc.  In  ulcerative  stomatitis  the  signs  and  symptoms  of  the  milder 
form  are  present,  but  are  more  intense.  The  ulceration  is  found  especially 
upon  the  gums,  in  the  vicinity  of  carious  teeth.  The  necks  of  the  teeth  are 
surrounded  by  a  collar  of  greenish-yellow  material  consisting  of  bacteria,  epi- 
thelial cells,  and  pus.  The  breath  is  commonly  fetid.  Ulcers  may  also  be 
developed  upon  the  cheeks,  opposite  a  sharp  carious  tooth,  in  the  floor  of  the 
mouth,  upon  the  tongue,  etc.  Salivation  is  often  present,  the  tongue  may  be 
swollen,  pain  and  tenderness  are  marked.  The  patients  are  only  able  to  take 
bland  soft  solids  and  liquids,  and  that  with  difficulty.  The  submaxillary  lymph 
nodes  are  enlarged  and  tender,  periostitis,  abscess,  etc.,  are  not  uncommon. 
(For  Gangrenous  Stomatitis,  see  Noma.)      (See  Fig.  1G0.) 

Thrush. — As  the  result  of  the   development  of  a  fungus    (saccharomyces 

albicans)  there  develop  in  the  mouths  of  suckling  and  teething  children  small, 

^483 


484     INJURIES   AND   DISEASES    OF   THE   MOUTH   AND   THKOAT 

grayish-white  plaques,  surrounded  by  a  narrow  inflamed  border.  The  plaques 
are  covered  by  a  thin  layer  of  dead  epithelium  in  which  the  fungus  is  growing. 
A  general  catarrhal  inflammation  of  the  mucous  membrane  of  the  mouth  is 
often  present.     Other  micro-organisms  are  usually  concerned  in  the  process. 

Erysipelas  of  the  Mucous  Membrane  of  the  Mouth  and  Throat. — Erysipelas 
of  the  mucous  membrane  of  the  mouth  and  throat  occurs,  usually,  as  an  exten- 
sion from  erysipelas  of  the  face,  less  commonly  as  a  primary  infection.  There 
is  intense  redness  of  the  mucous  membrane  of  the  mouth  and  throat,  marked 
swelling,  and  a  danger  of  asphyxia  from  edema  of  the  glottis.  (See  Ery- 
sipelas. ) 

Primary  and  Secondary  Syphilitic  Eruptions  of  the  Mouth  and  Throat. — Pri- 
mary and  secondary  syphilitic  eruptions  of  the  mouth  and  throat  have  been 
sufficiently  described  under  Syphilis. 

Gummata. — Gummata  may  occur  in  any  portion  of  the  mouth  and  throat. 
They  are  especially  common  in  the  tongue.  They  form  submucous,  or  more 
superficial,  nodules  of  varying  size,  which  break  down  and  leave  characteristic 
gummatous  ulcerations,  with  a  punched-out  and  undermined  border,  and  a  base 
covered  by  necrotic  material.  They  are  more  or  less  extensive  and  more  or  less 
destructive,  according  to  the  peculiarity  of  the  individual  case. 

THE    TONGUE 

Congenital  Deformities  of  the  Tongue  and  Floor  of  the  Mouth. — The  most 
common  deformity  of  the  tongue  is  congenital  shortening  of  the  frenum  of  the 
tongue.  When  it  is  of  a  high  grade  it  may  lead  to  disturbances  of  speech.  The 
mothers  of  infants  are  apt  to  overestimate  the  gravity  of  the  condition,  and  to 
request  an  operation  when  none  is  required.  When  children  have  grown  to 
be  five  or  six  years  of  age,  and  still  are  unable  to  speak  plainly,  it  is  some- 
times assumed  by  the  mother  that  the  child  is  suffering  from  tongue-tie; 
whereas,  often,  the  case  is  one  of  imperfect  cerebral  development.  A  con- 
genital deformity  sometimes  occurs,  such  that  the  entire  tongue  is  adherent, 
more  or  less  firmly,  to  the  floor  of  the  mouth,  as  far  forward  as  its  tip.  Cases 
have  also  been  described  in  which  the  frenum  of  the  tongue  was  too  long,  or, 
at  least,  the  tongue  was  too  movable,  so  that  it  fell  back  into  the  throat,  and 
caused  symptoms  of  asphyxia.  The  tongue  may  be  congenitally  fissured,  and 
the  fissure  may  be  of  any  extent,  from  a  slight  furrow  to  a  tongue  completely 
bifid  back  to  its  base.  The  tongue  may  be  abnormally  long  or  abnormally 
large.  (See  Lymphangioma  of  the  Tongue.)  An  acquired  atrophy,  usually 
of  one  side  of  the  tongue,  may  result  from  intracranial  hemorrhages  in  the 
region  of  the  center  of  the  hypoglossal  nerve,  or  from  tumors  of  the  brain,  cere- 
bral syphilis,  in  the  course  of  tabes  dorsalis,  progressive  muscular  atrophies, 
etc.,  or  from  division  of  the  hypoglossal  nerve. 

Injuries  of  the  Tongue. — The  most  frequent  injury  of  the  tongue  is  caused 
by  the  teeth.     The  tongue  is  often  bitten  during  epileptic  attacks,  and  a  history 


THE   TONGUE  485 

of  such  bites,  and  scars  upon  the  tongue,  is  a  diagnostic  feature  of  epilepsy. 
A  blow  upon  the  chin  while  the  tongue  is  protruded  will  produce  a  lacerated 
wound  of  the  tongue.  Further,  sharp  foreign  bodies  taken  into  the  mouth 
with  the  food,  stab  and  gunshot  wounds  of  the  tongue,  are  not  infrequent. 
Wounds  of  the  tongue  are  attended  by  free  bleeding,  and,  if  infected,  by  seri- 
ous and  even  dangerous  swelling.  The  bites  of  insects  upon  the  tongue  may 
also  be  attended  by  considerable  swelling,  usually  of  short  duration.  Burns 
of  the  tongue  are  caused  by  swallowing  hot  liquids,  and  are  quite  frequent  as 
the  result  of  swallowing  caustic  chemicals  by  accident,  or  with  suicidal  intent. 
Burns  of  the  tongue  produce,  as  upon  the  skin,  hyperemia,  vesication,  or  the 
formation  of  sloughs.  The  most  frequent  chemical  burn  of  the  tongue  is  pro- 
duced by  carbolic  acid.  The  eschars  during  the  first  few  hours  are  white,  and 
the  characteristic  odor  of  carbolic  acid  can  usually  be  detected.  Foreign  bodies 
may  heal  into  the  tongue  or  remain  for  years  without  producing  any  reaction 
(bullets,  sutures,  and  the  like)  or  they  may  cause  abscess. 

Inflammations  of  the  Tongue. — The  inflammations  of  the  tongue  occur  as  the 
result  of  infected  wounds,  from  infection  of  burns  of  the  tongue,  as  a  compli- 
cation of  acute  infectious  diseases,  and  of  severe  stomatitis.  Acute  inflamma- 
tion of  the  tongue  usually  runs  a  rapid  course.  The  tongue  swells  rapidly, 
sometimes  to  twice  or  thrice  is  normal  size,  becomes  more  or  less  immobile, 
speech  and  swallowing  are  interfered  with,  the  tongue  may  protrude  from  the 
mouth  and  become  dry,  there  may  be  serious  dyspnea.  The  condition  is  usually 
confined  to  one  half  of  the  tongue ;  it  may  end  in  resolution,  or  in  suppuration 
and  abscess.  The  presence  of  an  abscess  will  be  indicated  by  severe  septic  symp- 
toms, high  fever,  a  rapid  pulse,  localized  pain  and  tenderness,  sometimes  fluc- 
tuation to  be  felt  from  the  floor  of  the  mouth,  less  commonly  upon  the  dorsum 
of  the  tongue.  The  introduction  of  an  aspirating  needle  also  may  demon- 
strate the  presence  of  pus.  After  drainage  the  swelling  and  other  symptoms 
usually  subside  very  quickly.  Fatal  cases  from  general  sepsis  or  aspiration 
pneumonia  have  occurred. 

Tuberculosis  of  the  Tongue. — Tuberculosis  of  the  tongue  is  exceedingly  rare 
as  a  primary  infection,  and  occurs  usually  in  persons  with  well-marked  phthisis. 
In  the  cases  I  have  seen  the  ulcer  was  situated  upon  the  dorsum  of  the  tongue 
near  the  tip ;  it  was  round,  from  a  quarter  to  half  an  inch  in  diameter ;  the  base 
was  covered  by  a  soft  unhealthy  granulation  tissue,  in  which  could  be  seen 
small  caseating  nodules ;  the  ulcers  were  very  painful.  In  some  cases  the  ulcer 
may  be  deep  and  fungating.  The  base  of  the  ulcers  are  not  hard,  as  is  the  case 
with  cancer;  there  may  be  secondary  tubercles  in  the  vicinity.  A  diffuse  sub- 
miliary  tuberculosis  of  the  tongue  may  also  occur. 

Syphilis  of  the  Tongue. — All  three  stages  of  syphilis  may  occur  upon  the 
tongue.  Chancre  of  the  tongue  occurs  upon  the  dorsum  or  sides  of  the  front 
part  of  the  tongue.  It  occurs  as  a  sharply  circumscribed  nodular  infiltration, 
more  or  less  indurated,  from  a  quarter  to  half  an  inch  or  more  in  diameter, 
and  of  a  livid  red  color ;  induration  may  be  more  or  less  marked.     After  the 


486     INJURIES    AND   DISEASES    OF    THE   MOUTH   AND    THROAT 

epithelial  covering  is  lost  the  edges  of  the  ulcer  are  slightly  elevated,  the  cen- 
ter a  little  depressed,  raw,  and  granular,  or  covered  with  a  false  membrane. 
The  glands  of  the  submaxillary  region  soon  enlarge,  and  other  symptoms 
follow. 

Secondary  manifestations  are — during  the  early  stages  of  the  disease — 
mucous  patches,  already  described.  These  occur  especially  at  the  tip  and  along 
the  lateral  borders  of  the  tongue.  They  are  usually  accompanied  by  similar 
lesions  of  the  inner  surface  of  the  lips,  the  corners  of  the  mouth,  etc.  In  severe 
cases  true  ulceration  of  the  tongue  may  take  place  during  the  secondary  stage. 
The  ulcers  are  round,  usually  multiple,  their  edges  are  sharply  marked,  other 
manifestations  are  commonly  present.  Permanent  scars,  in  the  shape  of  fis- 
sures or  puckerings  upon  the  tongue,  may  follow  these  ulcerations.  The  gum- 
mata  of  the  tongue  are  not  uncommon;  they  usually  form  in  the  submucous 
tissue,  and  either  break  down,  forming  a  craterlike  ulcer  of  characteristic 
appearance  and  shape,  or  may  be  absorbed  without  ulceration.  They  are 
characterized  by  a  slow  course.  They  are  firm  or  elastic,  nodular  in  character, 
and  relatively  painless. 

Syphilitic  Sclerosis  of  the  Tongue. — Gummata  of  the  tongue  may  leave 
behind  dense  puckered  scars  and  even  notable  deformity  of  the  member.  An 
interesting  observation  was  made  by  me  in  a  case  of  tertiary  syphilitic  ulcer- 
ation of  the  tongue.  The  patient  was  a  young  man  who  presented  himself  with 
the  history  of  repeated  severe  attacks  of  vomiting  of  blood.  He  was  profoundly 
anemic.  A  probable  diagnosis  was  made  of  ulcer  of  the  stomach ;  further 
examination  showed  a  deep  tertiary  syphilitic  ulcer  situated  far  back  at  the 
base  of  the  tongue,  just  in  front  of  the  epiglottis,  from  which  the  hemorrhages 
had  occurred.  The  ulcer  healed  promptly  under  specific  treatment;  the  hema- 
temesis  did  not  recur. 

Actinomycosis  of  the  Tongue. — Actinomycosis  of  the  tongue  occurs  as  soli- 
tary or  multiple  nodules  in  the  tongue,  varying  in  size  from  the  head  of  a 
match  to  that  of  a  hazelnut.  The  nodules  are  in  the  anterior  half  of  the 
tongue.  For  a  long  time  the  mucous  membrane  is  adherent  over  them,  but 
intact.  They  are  moderately  hard.  They  may  ulcerate,  and,  if  incised,  they 
discharge  a  little  pus  containing  actinomyces  granules.  The  cavity  of  the 
abscess  is  filled  with  soft  granulations,  and  there  are  apt  to  be  little  under- 
mined pockets,  here  and  there,  communicating  with  it.  The  appearance  is 
unlike  the  dirty-yellowish,  shreddy,  broken-down  base  of  a  gumma. 

Infection  and  Inflammation  of  the  So-called  Lingual  Tonsil. — Infection  and 
inflammation  of  the  so-called  lingual  tonsil,  at  the  base  of  the  tongue,  is  some- 
times followed  by  abscess.  The  symptoms  are  those  of  an  abscess  of  the  back 
part  of  the  tongue.  It  is  especially  likely  to  be  followed  by  edema  of  the 
glottis. 

leukoplakia  of  the  Tongue.- — Leukoplakia  of  the  tongue,  regarded  by  many 
observers  as  identical  with  psoriasis,  ichthyosis,  keratosis,  smoker's  patches  of 
the  tongue,  is  a  chronic  disease  characterized  by  the  slow  formation  of  opaque, 


THE   TONGUE  487 

milk-white  spots  upon  the  surface  of  the  tongue,  less  often  upon  the  cheek, 
gums,  and  lips.  Upon  the  tongue  they  form  white,  slightly  uneven,  or  wrinkled, 
milk-white  areas  which  appear  to  be  slightly  elevated  above  the  general  surface. 
There  are  often  superficially  ulcerated  cracks  and  fissures  crossing  the  white 
surface ;  they  are  confined  to  the  anterior  half  of  the  tongue.  The  plaques  are 
very  sharply  marked,  of  irregular  contour;  they  are  often  multiple;  they  may 
cover  a  large  part  of  the  surface  of  the  tongue.  The  cracks  and  fissures  often 
bleed  upon  mechanical  irritation.  Upon  palpation  the  diseased  area  feels  quite 
hard.  The  disease  is  at  first  not  markedly  painful,  but  as  time  goes  on  the 
tongue  becomes  stiff,  so  that  articulation  may  be  troublesome.  As  the  ulcers 
and  fissures  increase  in  number  and  depth,  they  become  more  and  more  sensi- 
tive, until  eating  and  drinking  becomes  a  torture.  The  disease  is  peculiarly 
interesting  because  many  of  the  cases  of  carcinoma  of  the  tongue  are  preceded 
by  this  condition  of  leukoplakia. 

Tumors  of  the  Tongue. — Angioma  of  the  Tongue. — Angioma  of  the 
tongue  occurs  as  angioma  simplex  and  as  cavernous  angioma.  Angioma  sim- 
plex occurs  in  the  form  of  small  slightly  elevated  patches  of  a  deep  blue-red 
color,  sometimes  bright  red,  upon  the  surface  of  the  tongue;  less  often  they 
are  more  deeply  seated  in  the  substance  of  the  tongue.  They  seldom  exceed 
three  fourths  of  an  inch  in  diameter;  they  may  be  single  or  multiple,  may 
remain  stationary,  or  grow  into  tumors  of  some  size.  Cavernous  angioma 
occurs  in  the  form  of  single  or  multiple,  blue  or  red  nodules  upon  the  surface, 
or  in  the  substance  of  the  tongue.  They  are  sometimes  erectile — i.  e.,  they 
increase  in  size  when  the  head  is  bent  forward,  upon  coughing,  straining,  etc. 
They  are  soft  and  compressible  like  a  sponge,  and  regain  their  size  at  once 
when  the  pressure  ceases.  They  may  also  remain  stationary  or  grow  into  pretty 
large  tumors.  There  is  always  serious  danger  from  hemorrhage  due  to  slight 
accidental  wounds  and  from  infection. 

Lymphangioma  of  the  Tongue. — Lymphangioma  of  the  tongue  may  be: 
(1)  Simple;  (2)  cystic;  (3)  cavernous.  Most  of  the  cases  of  congenital  and 
acquired  enlargements  of  the  tongue  (macroglossia)  are  congenital  cavernous 
lymphangiomata,  or  combinations  of  lymphangioma  with  hemangioma.  The 
enlargement  may  be  so  great  that  the  tongue  cannot  be  retained  in  the  mouth, 
and  constantly  protrudes  through  the  lips.  The  enlargement  may  not  be  noticed 
at  birth,  or  until  the  tongue  is  considerably  increased  in  size.  The  protruded 
portion  of  tongue  is  of  a  deep-red  color ;  and  becomes  fissured,  excoriated,  even 
ulcerated.  A  deep  furrow  exists  at  the  line  of  the  teeth.  Speech,  swallowing, 
and  breathing  are  notably  interfered  with.  Attacks  of  inflammation  occur 
from  time  to  time,  and  make  the  condition  worse.  Cystic  lymphangioma  occurs 
in  the  form  of  larger  or  smaller  cystic  nodules,  simple  or  conglomerate,  on 
the  surface  of  or  in  the  substance  of  the  tongue,  .filled  with  clear  or  cloudy 
lymph. 

Sarcoma  of  the  Tongue. — Sarcoma  of  the  tongue  is  a  rare  tumor,  a  few 
cases  are  reported.     They  possess  certain  definite  peculiarities.     They  remain 


488     INJURIES    AND    DISEASES    OF    THE    MOUTH   AND    THROAT 

often  small  and  stationary  for  some  time,  and  then  grow  rapidly.  They  are 
very  painful,  ulcerate  early  and  deeply. 

Cystic  Tumors  of  the  Tongue. — Small  mucous  cysts  occur  beneath  the 
tongue,  in  the  floor  of  the  mouth,  and  in  the  mucous  membrane  of  the  cheeks 
as  small,  translucent,  bluish,  bladderlike  elevations  upon  the  surface,  contain- 
ing clear  stringy  mucus.  Similar  cysts  may  occur  at  the  back  of  the  tongue 
in  connection  with  the  lingual  tonsil. 

Banula. — Mucous  cysts  of  considerable  size  occur  beneath  the  tongue  and 
the  floor  of  the  mouth,  to  one  side  of  the  frenum,  between  the  tongue  and  the 
jaw;  they  are  very  rare  in  the  middle  line.  Ranula  appears  like  a  thin, 
rounded,  pale-red,  or  bluish-white,  translucent,  bladderlike  formation  beneath 
the  tongue,  covered  by  normal  mucous  membrane,  tense,  but  movable  over  the 
surface  of  the  cyst.  The  contents  are  clear  mucus  closely  resembling  egg  albu- 
men; rarely  the  mucus  is  yellow  or  brown  in  color.  A  ranula  may  be  (1)  a 
cyst  of  Bochdalek's  glands;  (2)  a  cyst  of  the  Blandin-Nuhn  gland  at  the  apex 
of  the  tongue;  (3)  a  retention  cyst  of  the  sublingual  gland  or  of  the  so-called 
glandula  incisiva. 

Dermoid  Cysts. — Dermoid  cysts  of  the  floor  of  the  mouth  are  congenital 
tumors,  but  may  not  grow  to  sufficient  size  to  be  noticed  for  some  time.  They 
present  in  the  middle  line  of  the  mouth  beneath  the  tongue,  or  beneath  the 
chin ;  they  are  very  rarely  to  one  side  of  the  middle  line.  They  form  globular 
or  semiglobular  tumors  of  elastic  consistence.  They  may  be  mistaken  for 
lipoma,  or,  possibly,  for  ranula.  Their  median  situation  and  their  contents 
establish  the  diagnosis. 

Rare  Tumors  or  the  Tongue. — Lipoma  is  a  rare  tumor  of  the  tongue. 
They  are  sessile,  or  pedunculated  tumors  of  the  dorsum,  borders,  or  tip  of  the 
tongue.  They  may  be  embedded  in  the  muscular  tissue  of  the  tongue  itself. 
Other  rare  tumors  of  the  tongue  are  fibroma,  chondroma,  osteoma.  The 
so-called  papilloma  of  the  tongue  is  a  small,  sessile,  or  pedunculated  tumor  of 
the  dorsum  of  the  tongue,  as  large  as  a  pea  or  a  hazelnut.  The  surface  is 
granular  and  rough.  They  are  not  painful,  and  rarely  give  rise  to  any  symp- 
toms. Some  of  the  papillary  outgrowths  from  the  tongue  are  true  benign 
epitheliomata,  and  resemble  in  structure  the  acuminate  warts  of  the  prepuce 
and  elsewhere.  A  more  massive  fibrous  tumor  of  very  slow  growth  has  occa- 
sionally been  observed  in  the  substance  of  the  tongue.  Endotheliomata  of  the 
tongue  have  been  described  as,  for  the  most  part,  slow-growing  tumors,  showing 
hyaline  and  other  forms  of  degeneration.  Their  diagnosis  would  be  for  the 
pathologist  to  make,  after  removal.  Adenoma  may  occur  as  circumscribed 
nodular  tumors  of  the  substance  of  the  tongue.  Superficially  they  may  resem- 
ble polypoid  growths.  The  glandular  tissue  may  resemble  an  acinous  gland  or 
the  tissue  of  the  thyroid  gland — when  they  are  known  as  struma  of  the  tongue. 

Cancer  of  the  Tongue. — By  far  the  most  interesting  and  important 
tumor  of  the  tongue  is  cancer.  Even  under  the  best  of  conditions  it  is  one  of 
the  most  painful  and  fatal  of  malignant  diseases,  and  its  early  diagnosis  is 


THE   TONGUE  489 

therefore  highly  important.  There  seems  to  he  no  doubt  that,  in  some  coun- 
tries at  least,  cancer  is  becoming  more  frequent ;  for  example,  in  England,  sta- 
tistics seem  to  show  that  cancer  of  the  tongue  has  become  more  than  four  times 
as  frequent  in  the  last  twenty-five  years.  The  disease  is  nearly  ten  times  as 
frequent  in  men  as  in  women.  Cancer  of  the  tongue  arises  in  the  tongue 
itself;  in  the  mucous  membrane  of  the  cheek  or  of  the  floor  of  the  mouth. 
Chronic  irritations  of  the  mucous  membranes  seem  to  play  a  very  important 
part  in  the  production  of  cancer  of  the  tongue,  and  it  has  been  supposed  that 
the  greater  use  of  tobacco  and  of  alcohol  among  men  might  account,  in  part  at 
least,  for  the  more  frequent  occurrence  of  cancer  of  the  tongue  in  the  male  sex. 
The  chronic  irritation  produced  by  the  sharp  borders  of  carious  teeth  is  an 
exciting  cause  in  a  certain  proportion  of  cases.  Chronic  syphilitic  ulcers  of 
the  tongue  are  followed  by  cancer  in  some  instances,  and  the  same  is  true  of 
tubercular  and  other  chronic  ulcerations.  The  disease  is  most  frequent  between 
the  ages  of  forty-five  and  sixty-five ;  in  a  small  percentage  of  cases  it  has 
occurred  before  the  age  of  thirty. 

The  type  of  the  disease  is  nearly  always  that  of  flat  epithelial  cancer.  It 
begins  either  in  the  form  of  a  papillary  outgrowth,  an  indurated  nodule  in 
the  substance  of  the  tongue,  a  fissure,  or  as  an  ulcer.  In  all  the  forms,  indura- 
tion and  early  ulceration  are  prominent  symptoms.  In  some  cases,  in  addi- 
tion to  progressive  ulceration  and  infiltration  of  the  surrounding  tissues,  there 
are  formed  fungating  papillary  outgrowths  of  cancerous  tissue,  which  may 
form  ragged,  uneven,  warty-looking  prominences  of  some  size,  suggesting  in 
outline  a  cockscomb.  The  tumor  tissue  is  characterized  by  hardness,  by  infil- 
tration of  the  surrounding  structures,  and  immobility.  The  base  of  the  ulcer- 
ated surface  is  uneven,  ragged,  and  fissured.  The  tumor,  from  the  very  start, 
has  no  sharply  circumscribed  boundaries ;  the  induration  gradually  fades  off 
into  the  surrounding  tissues.  The  borders  of  the  ulcerated  area  are  ragged, 
elevated,  indurated,  and  undermined.  A  necrotic  inflammation  develops  on 
the  raw  surface  early  in  the  disease,  giving  it  a  dirty  greenish-gray  appearance. 
As  in  epithelioma  of  the  lip,  it  is  often  possible  to  express  from  the  raw  surface 
epithelial-cell  nests  in  the  form  of  columns  and  pearls.  In  certain  instances 
the  disease  may  begin  as  a  diffuse  induration,  or  as  a  nodule,  in  the  sub- 
stance of  the  tongue,  which  only  begins  to  ulcerate  after  it  has  reached  the 
surface. 

The  further  progress  of  the  disease  is  characterized  by  putrefactive  changes 
in  the  necrotic  tissue  and  a  stinking  fetid  odor.  Marked  salivation  is  usually 
present.  Hemorrhages  take  place  from  the  ulcerated  surface  spontaneously,  or 
from  slight  mechanical  irritation.  Pain  is  a  marked  symptom ;  the  pain  is  felt 
in  the  tongue  and  radiates  toward  the  ear.  As  the  disease  advances,  the  neigh- 
boring structures  are  affected — the  floor  of  the  mouth,  causing  the  tongue  to 
become  immobile,  affecting  deglutition  and  speech.  The  disease  spreads  to 
the  gums,  the  cheeks,  the  palatine  arches,  and  the  tonsils.  The  lymph  glands 
of  the  submaxillary  region  are  very  early  involved.     The  disease  also  infiltrates 


490     INJUKIES    AND    DISEASES    OF    THE    MOUTH   AND    THEOAT 

the  lower  jaw.  If  it  extends  toward  the  parotid  region,  the  jaws  may  be  firmly 
closed  and  the  patient  unable  to  open  his  month.  Death  occurs  in  from  a  year 
to  a  year  and  a  half  in  unoperated  cases — from  exhaustion,  hemorrhage,  pneu- 
monia, sepsis. 

The  diagnosis  of  cancer  of  the  tongue  is  usually  easy.  It  may,  however, 
be  confounded  with  syphilis,  tuberculosis,  actinomycosis,  a  benign  papilloma, 
a  pressure  ulcer,  caused  by  the  irritation  of  a  decayed  tooth,  and  perhaps  other 
conditions.  In  any  case  where  the  slightest  doubt  exists,  a  sufficient  portion 
of  the  diseased  tissue,  including  a  little  of  the  apparently  healthy  tissue  of 
the  vicinity,  should  be  excised  under  cocain  anesthesia,  and  subjected  to  a 
microscopical  examination.  The  alveolar  structure  of  the  epithelioma,  with  its 
epithelial-cell  nests  and  pearls,  is  so  characteristic  that  the  diagnosis  of  cancer 
can  be  made  at  a  glance  when  they  are  present.  Syphilis  and  tubercle  are  dis- 
tinguishable by  their  histological  characters,  and  tubercle  also  by  the  recogni- 
tion of  bacilli.  It  is  to  be  remembered,  in  regard  to  cancer  of  the  tongue,  that 
a  very  early  diagnosis  is  absolutely  essential,  so  that  immediate  operation  may 
give  the  unfortunate  patient  his  only  chance  of  cure. 

THE    PALATE,    TONSILS,    AND    PHARYNX 

Cleft  Palate. — The  various  degrees  of  cleft  palate,  complete  and  incomplete, 
have  already  been  described.  Their  recognition  is,  of  course,  entirely  simple, 
and  they  require  no  further  comment.  Various  defects  of  the  hard  and  soft 
palate  may  occur  as  acquired  conditions,  especially  from  syphilitic  ulcerations, 
less  commonly  from  tuberculosis  or  from  injury.  They  differ  much  in  extent, 
situation,  and  character,  and  are  recognizable  upon  inspection.  Defects  in  the 
hard  and  soft  palate  always  give  the  voice  a  nasal  quality,  and  if  the  defect  is 
extensive,  the  resonant  tone  of  the  normal  voice  is  lost.  The  admixture  of  the 
contents  of  the  nose  and  mouth  constitute  a  disagreeable  condition. 

Injuries  of  the  Palate,  Tonsils,  and  Pharynx. — Injuries  of  the  palate,  the 
tonsils,  and  the  pharynx  are  not  very  common.  They  occur  most  often  when 
an  individual  falls  upon  his  face  while  carrying  some  pointed  object  in  his 
mouth — a  lead  pencil  or  the  like — also  from  stab  wounds,  and  quite  often 
from  suicidal  gunshot  wounds.  They  may  be  attended  by  sharp  hemorrhage 
from  the  palate,  and  especially  from  the  ascending  pharyngeal  artery,  less 
commonly  from  the  internal  carotid.  The  pharynx  is  occasionally  wounded 
by  gunshot  or  stab  wounds  beneath  the  chin  or  at  the  side  of  the  neck.  I  once 
saw  a  woman  who  had  been  wounded  in  the  side  of  the  neck  by  her  husband, 
who  used  a  carving  knife  for  the  purpose.  The  wound  extended  from  in  front 
of  the  ear  to  below  the  angle  of  the  jaw,  along  the  anterior  border  of  the 
sterno-mastoid  muscle.  The  knife  divided  the  facial  nerve  and  penetrated  into 
the  pharynx ;  the  external  carotid  artery  was  plainly  exposed  in  the  wound — 
as  in  a  dissection — but  was  not  injured.  The  hemorrhage  from  this  wound 
was  moderate.     The  facial  paralysis  was  permanent  in  spite  of  several  efforts 


THE    PALATE,    TONSILS,    AND    PHARYNX  491 

to  suture  the  nerve.  In  all  wounds  of  the  upper  part  of  the  pharynx  there  is 
danger  of  edema  of  the  glottis,  and  serious  or  fatal  dyspnea. 

Foreign  Bodies  in  the  Mouth  and  Pharynx. — Foreign  bodies  of  the  most 
varied  description  may  be  taken  into  the  mouth,  either  by  accident  or  design, 
and  become  embedded  in  the  tongue,  the  floor  of  the  mouth,  the  palate,  occa- 
sionally in  the  orifice  of  Steno's  duct,  or  become  lodged  in  the  pharynx,  or 
behind  the  palate,  or  above,  in  the  posterior  nares.  Such  bodies  may  be  sharp, 
such  as  pins,  fish  bones,  sharp  fragments  of  bone  contained  in  meat,  or  the 
like,  or  they  may  be  blunt  bodies,  such  as  buttons  or  coins,  or  simply  large 
masses  of  food  or  sets  of  false  teeth.  In  the  case  of  sharp  bodies  it  quite 
often  happens  that  the  body  slightly  wounds  the  wall  of  the  pharynx,  the  back 
of  the  tongue,  or  the  upper  part  of  the  esophagus,  but  is  really  swallowed.  If 
such  is  the  case,  it  is  usually  safe,  after  a  careful  examination,  to  assure  the 
patient  that  in  all  probability  the  foreign  body  wTill  do  no  harm,  especially 
if  purgatives  are  avoided,  and  a  diet  of  boiled  potatoes,  or  the  like,  is  pre- 
scribed. Bodies  which  are  embedded  in  the  tongue,  the  palate,  the  cheeks, 
or  the  posterior  wall  of  the  pharynx  can  usually  be  detected  readily  enough 
by  direct  inspection  of  the  cavity  of  the  mouth  and  throat,  aided  by  daylight, 
the  use  of  a  tongue  spatula,  or  by  artificial  light  with  a  head  mirror.  The 
patient  should  be  asked  to  phonate,  when  the  muscular  movements  may  bring 
the  foreign  body  into  view.  The  upper  part  of  the  nasopharynx  can  be  exam- 
ined by  posterior  rhinoscopy  and  palpation.  In  a  large  proportion  of  cases 
sharp  foreign  bodies  get  caught  in  the  lowest  position  of  the  pharynx,  or  in 
the  sinus  pyroformis.  They  may  be  discovered  by  laryngoscopy  or  by  palpa- 
tion. Bodies  caught  in  the  sinus  pyroformis  are  very  apt  to  cause  inflam- 
mation and  edema  of  the  glottis  if  they  are  not  removed,  and  may  cause  an 
abscess  only  approachable  by  subhyoid  pharyngotomy. 

In  case  the  body  has  passed  down  into  the  esophagus  and  become  impacted, 
its  presence  can  usually  be  detected  by  the  passage  of  the  esophageal  bougie 
of  the  bulbous  variety,  or  with  the  so-called  "  coin  catcher."  If  the  bodies  are 
metallic  and  of  sufficient  size,  they  may  often  be  detected  by  means  of  an 
X-ray  picture.  Large  bodies — such  as,  for  example,  pieces  of  meat  too  large 
to  pass  through  the  esophagus — may  cause  immediate  death  by  asphyxia  when 
they  occlude  or  engage  in  the  orifice  of  the  larynx.  Sharp  bones,  pins,  and 
other  similar  bodies,  which  are  permitted  to  remain  in  situ  in  the  pharynx 
or  esophagus,  may  cause  ulceration  by  pressure  and  serious  hemorrhage,  or 
they  may  pass  into  the  trachea  and  cause  death  by  septic  pneumonia,  or  ulcer- 
ate into  the  pleura  or  mediastinum,  with  fatal  results. 

Acute  Inflammatory  Affections  of  the  Pharynx  and  Tonsils. — The  tonsils  afford 
a  frequent  and  favorable  avenue  for  the  entrance  of  bacteria.  Many  local  and 
general  infections  are  acquired  through  this  channel.  The  mouth  is  the  habitat 
of  numerous  and  varied  forms  of  bacteria,  and  while  during  robust  health  the 
pathogenic  forms  may  be  only  slightly  virulent,  yet  in  conditions  of  local  con- 
gestion, or  catarrhal  inflammation  of  the  throat,  they  appear  to  acquire   an 


492     IX JURIES   &KD   DISEASES    OF   THE   MOUTH   AND   THROAT 

increased  virulence.  The  various  varieties  of  pyogenic  cocci — notably  the 
streptococcus,  the  pnemnococcus,  the  diphtheria  bacillus,  and  many  other 
forms — may  be  found  in  the  crypts  of  the  tonsils. 

The  ordinary  forms  of  tonsillitis  may  be  divided  into  catarrhal,  follicular, 
and  parenchymatous  tonsillitis. 

Catarrhal  Tonsillitis. — The  simple  catarrhal  form  is  usually  combined 
with  a  catarrhal  pharyngitis  which  involves  the  posterior  wall  of  the  pharynx, 
the  soft  palate,  and  occasionally  extends  downward  as  far  as  the  opening  into 
the  larynx,  involving  the  epiglottis.  The  mucous  membrane  of  the  tonsils — 
usually  both  are  involved — is  reddened  and  swollen,  and  a  similar  intense  red- 
ness is  to  be  noted  on  the  posterior  pharyngeal  wall  and  the  soft  palate.  The 
local  symptoms  are  a  sensation  of  soreness  in  the  back  of  the  throat  and  pain 
on  swallowing;  the  throat  feels  raw.  In  mild  cases  the  patients  may  feel  quite 
well,  or  there  may  be  a  little  fever,  chilly  sensations,  or  even  a  chill,  and 
some  constitutional  depression.  In  other  cases,  even  where  the  throat  is  not 
intensely  inflamed,  the  fever  may  be  quite  high ;  there  may  be  severe  headache, 
loss  of  appetite,  pains  in  the  muscles — notably  at  the  back  of  the  neck — and  in 
the  back,  and  marked  prostration.  In  children  there  may  be  severe  headache, 
sometimes  delirium  and  convulsions.  In  the  catarrhal  form  the  general  and 
local  symptoms  usually  subside  after  three  or  four  days. 

Follicular  Tonsillitis. — The  inflammatory  process  in  follicular  tonsil- 
litis is  most  marked  in  the  walls  of  the  follicles  or  crypts  of  the  tonsil.  One 
tonsil  may  be  involved,  or  both,  or  first  one  and  then  the  other.  Upon  looking 
into  the  throat,  in  addition  to  more  or  less  marked  general  redness  of  the 
pharynx  one  or  many  of  the  orifices  of  the  crypts  of  the  tonsil  are  seen  occu- 
pied by  little  white  or  yellow  masses  of  exudate,  consisting  of  epithelium, 
pus  cells,  bacteria,  and  granular  detritus.  There  may  be  the  production  of 
considerable  areas  of  false  membrane  upon  the  surface  of  the  tonsil,  which 
can  sometimes  be  wiped  away  easily  and  sometimes  not,  but  does  not  leave  a 
distinct  raw  surface  or  loss  of  substance.  The  differential  diagnosis  from 
diphtheria  is  only  possible  by  means  of  cultures  from  the  throat.  The  pres- 
ence or  absence  of  diphtheria  bacilli  can  thus  be  determined  in  twenty-four 
hours.  The  constitutional  symptoms  vary  much  in  intensity  and  duration. 
There  is  often  an  initial  chill,  a  marked  rise  of  temperature,  severe  headache, 
notable  prostration,  etc.  On  the  other  hand,  the  general  symptoms  may  be 
slight  or  absent. 

Parenchymatous  Tonsillitis. — The  general  symptoms  are  marked.  Pain 
in  the  throat  is  severe  ;  the  tonsils  are  notably  swollen  ;  swallowing  and  speaking 
are  painful ;  there  may  be  inflammatory  lockjaw.  The  process  is  often  a  fore- 
runner of  peritonsillar  infection  and  abscess.  In  any  of  the  forms  of  acute 
tonsillitis  the  lymph  nodes  at  the  angle  of  the  jaw  may  be  swollen  and  tender. 
In  the  more  severe  cases  the  patient  is  apt  to  hold  his  head  rather  stiffly,  and 
turned  a  little  to  one  side — a  mild  torticollis,  involuntarily  assumed,  probably 
to  relieve  tension  and  pressure  and  to  avoid  motion  of  the  tender  throat. 


THE   PALATE,   TONSILS,   AND   PHAKYNX  493 

Differential  Diagnosis. — A  syphilitic  pharyngitis  may  simulate  quite 
closely  an  ordinary  acute  tonsillitis  and  pharyngitis.  It  will  usually  be  found 
that  the  syphilitic  throat  has  come  on  more  gradually,  and  has  lasted  longer 
before  the  patient  consults  a  physician  than  is  the  case  with  ordinary  attacks. 
In  early  sypliilitic  pharyngitis  an  arch  of  redness  extending  completely  across 
the  soft  palate  above  the  uvula  is  thought  to  be  characteristic.  It  is  to  be 
remembered  that  in  many  cases  of  diphtheria  the  local  lesion  in  the  throat 
is  by  no  means  extensive  or  characteristic,  and  that  cultures  should  be  taken 
from  the  throat  in  all  doubtful  cases.  Moreover,  as  indicated,  many  general 
diseases  at  the  time  of  invasion — notably  scarlet  fever,  measles,  etc. — may  pre- 
sent the  local  signs  of  pharyngitis  and  tonsillitis. 

Herpes  of  Throat  and  Tonsils. — Herpes  of  the  throat  and  tonsils  occurs  in 
the  form  of  small  vesicular  spots.  Almost  at  once  they  change  to  flat  erosions, 
which  soon  are  covered  with  false  membrane,  and  may  coalesce.  They  are 
surrounded  by  an  inflammatory  areola.  Their  simultaneous  appearance  on  the 
face  may  aid  the  diagnosis. 

Diphtheria. — Diphtheria  often  begins  in  one  or  more  of  the  follicles  of  the 
tonsil.  For  the  diagnosis  the  reader  is  referred  to  works  on  general  medicine. 
Suffice  it  to  say  that  the  recognition  of  the  characteristic  growth  and  staining 
reactions  of  the  bacilli  are  the  means  chiefly  relied  upon  at  present  for  a 
diagnosis,  in  cities  at  least. 

Peritonsillar  Abscess. — Infection  of  the  tonsillar  tissue  with  pus  microbes 
causes  abscess  of  the  peritonsillar  structures  more  often  than  abscess  of  the 
tonsil  itself,  although  the  abscess  sometimes  points  on  the  surface  of  the  tonsil. 
The  formation  of  an  abscess  may  be  preceded  by  an  attack  of  catarrhal  or 
follicular  tonsillitis,  or  begin  independently.  The  signs  and  symptoms  are 
constitutional  and  local.  The  general  symptoms  are  those  of  a  sharp  invasion 
of  sepsis,  often  a  chill,  a  rapid  rise  of  temperature,  prostration,  a  rapid  pulse, 
headache,  etc.  The  local  signs  and  symptoms  are  pain,  of  a  severe,  throbbing 
character,  in  the  throat;  difficulty  and  pain  in  swallowing,  speaking,  and  even 
breathing.  There  is  usually  inflammatory  lockjaw,  more  or  less  complete. 
Swallowing  may  become  impossible ;  there  will  be  drooling  of  saliva  or  fre- 
quent expectoration. 

Inspection  of  the  throat  may  be  difficult.  A  general  anesthetic  and  the  use 
of  a  gag  may  even  be  necessary  before  the  mouth  can  be  properly  opened.  A 
marked  swelling  will  be  noted  on  one  side  of  the  throat.  The  pillars  of  the 
fauces  and  the  tonsil  are  displaced  toward  the  middle  line ;  the  tonsil  is  partly 
or  entirely  hidden  by  the  swollen  anterior  pillar.  The  uvula  is  swollen  and 
edematous.'  The  anterior  pillar,  half  the  soft  palate,  and  the  mucous  mem- 
brane— as  far  forward  as  the  last  tooth — are  of  a  deep  violet-red  color.  Pal- 
pation reveals  a  tender  mass  of  induration — rarely  fluctuation — the  center  of 
which  often  lies  at  the  mid-point  of  a  line  connecting  the  base  of  the  uvula 
with  the  last  motor  tooth  of  the  lower  jaw  on  the  affected  side.  In  most  cases 
the  abscess  approaches  the  surface  at  this  point ;  more  rarely  the  pus  lies  pos- 


494     INJURIES   AND   DISEASES    OF   THE   MOUTH   AND   THROAT 

teriorly  and  lower  down,  and  is  apt  to  rupture  through  the  posterior  pillar 
near  the  entrance  to  the  larynx.  In  such  cases  the  posterior  pillar  forms  a 
ridge  or  prominence,  which  unites  with  the  posterior  pharyngeal  wall. 

The  progress  of  the  disease  is  rapid.  The  abscess  usually  evacuates  itself, 
unless  incised,  in  from  three  to  ten  days,  followed  by  subsidence  of  the  symp- 
toms. If  the  abscess  bursts  posteriorly,  the  pus  may  flow  into  the  larynx  and 
cause  dangerous  dyspnea,  or  even  asphyxia.  In  rare  cases  infection  of  the 
internal  jugular  vein  may  lead  to  pyemia.  Cases  of  ulceration  of  the  internal 
carotid  artery  and  fatal  hemorrhage  have  been  reported.  The  pus  may  travel 
down  the  intermuscular  planes  of  the  neck  and  produce  infection  of  the  medi- 
astinum. The  glands  at  the  angle  of  the  jaw  are  usually  swollen,  and  may 
suppurate.  Infection  of  the  pterygoid  plexus  of  veins  is  possible,  with  sinus 
thrombosis  and  fatal  meningitis.  It  is  to  be  remembered  that  infection  from 
the  neighborhood  of  the  last  molar  tooth  may  cause  an  abscess  in  the  periton- 
sillar region  identical  in  situation  with  that  proceeding  from  the  tonsil  itself. 
A  malignant  tumor  originating  in  the  tonsil,  of  rapid  growth,  may  cause 
appearances  and  symptoms  not  unlike  a  peritonsillar  abscess,  and  in  cases  of 
doubt  an  exploratory  puncture  with  an  aspirating  needle  is  desirable,  since  the 
incision  of  a  malignant  growth  would  probably  be  followed  by  serious  hemor- 
rhage. A  chancre  of  the  tonsil  would  present  characteristic  ulceration  and 
induration,  together  with  an  absence  of  septic  symptoms.  Hard,  enlarged, 
insensitive  lymph  nodes  are  present  at  the  angle  of  the  jaw. 

Retropharyngeal  Abscess. — Retropharyngeal  abscess  occurs,  for  the  most 
part,  during  infant  life  and  childhood.  In  babies  it  often  results  from  infec- 
tion of  the  retropharyngeal  lymphatic  tissue,  complicating  measles,  scarlet 
fever,  etc. ;  occasionally  as  the  result  of  repeated  attacks  of  tonsillitis ;  rarely 
following  catarrhal  inflammations  of  the  nose  and  throat,  or  infections  of  the 
orbit  or  the  ear.  A  subacute  or  chronic  retropharyngeal  abscess  may  follow 
tuberculous  disease  of  the  base  of  the  skull,  or  of  the  bodies  of  the  upper 
cervical  vertebra?.  The  signs  and  symptoms  of  retropharyngeal  abscess  of  the 
acute  type  are  general  symptoms  of  sepsis,  and  local  symptoms  due  to  inter- 
ference with  swallowing  and  with  respiration.  The  interference  is  partly 
caused  by  the  size  of  the  pus  sac  in  the  back  of  the  throat  and  partly  due  to 
inflammatory  swelling  of  the  mucous  membrane,  notably  to  edema  of  the  larynx. 
The  diagnosis  is  made  by  palpation  of  the  back  of  the  throat.  In  the  early 
stages  a  tender,  firm,  or  elastic  mass  can  be  felt  projecting  from  or  filling  the 
posterior  wall  of  the  pharynx;  later,  fluctuation  may  be  evident.  The  inter- 
ference with  breathing  will  produce  noisy  breathing,  cyanosis,  and  other  signs 
of  dyspnea.  The  septic  symptoms  are  apt  to  be  predominant  and  grave.  In 
little  children,  palpation  of  the  throat  affords  far  more  information  than  does 
inspection.  In  the  cases  due  to  tubercular  disease  the  signs  and  symptoms  of 
sepsis  will  be  absent.  There  will  be  interference  with  swallowing  and  dyspnea ; 
a  fluctuating  swelling  will  be  felt  in  the  back  of  the  throat  on  palpation.  The 
chronic  form  of  abscess  is  spoken  of  under  diseases  of  the  vertebra?. 


THE   PALATE,    TONSILS,   AND   PHARYNX  495 

Chronic  Inflammation  of  the  Tonsils.  Hypertrophy  of  the  Tonsils. — Chronic 
inflammation  of  the  tonsils  may  follow  repeated  attacks  of  acute  inflammation 
of  the  tonsils  and  pharynx;  more  commonly  it  is  a  condition  noted  especially 
in  childhood,  and  associated  with  adenoid  growths  of  the  vault  of  the  pharynx. 
The  enlargement  of  the  tonsils  is  easily  recognized  by  inspection  of  the  throat. 
The  tonsils  project  on  either  side  toward  the  median  line,  and  more  or  less 
completely  fill  the  back  of  the  throat ;  they  form  rounded,  more  or  less  tabu- 
lated red  tumors,  wTith  an  uneven  surface,  upon  which  the  orifices  of  the  crypts 
of  the  tonsil  are  easily  recognizable.  In  some  cases  the  enlargement  of  the 
tonsils  interferes  seriously  with  respiration,  and  with  the  development  and 
nutrition  of  these  children.  They  are  often  mouth-breathers,  and  notably  so 
at  night,  when  they  are  apt  to  snore.  They  are  often  anemic ;  the  expression 
of  the  face  is  dull,  the  eyelids  droop,  the  nostrils  are  narrow,  the  voice  is 
thick.  The  children  are  easily  exhausted  and  put  out  of  breath ;  slight  exertion 
may  bring  on  a  violent  fit  of  coughing,  during  which  the  child  feels  as  though 
he  had  a  foreign  body  in  the  throat  which  must  be  expelled.  Speech  and  the 
sense  of  hearing,  taste,  and  smell,  are  often  impaired.  There  may  be  nervous 
symptoms,  such  as  chorea  and  epilepsy.  The  enlargement  of  the  tonsils  is  not 
infrequently  combined  with  an  arched  palate,  and  occasionally  with  that  de- 
formity of  the  chest  known  as  "  pigeon  breast."  Chronic  atrophic  rhinitis 
may  be  associated  with  atrophy  of  the  tonsils  and  an  atrophic  pharyngitis. 

The  Uvula. — Elongation  of  the  uvula  occurs  as  a  congenital  deformity — 
which,  however,  rarely  produces  symptoms  during  the  early  years  of  life;  and 
as  an  acquired  condition,  from  chronic  pharyngitis  the  uvula  may  be  too  long, 
so  that  it  irritates  the  base  of  the  tongue  and  the  epiglottis ;  a  sense  of  tickling 
and  irritation  in  the  back  of  the  throat  may  result,  with  a  chronic  throat  cough 
and  the  habit  of  frequently  clearing  the  throat. 

Leptothrix. — Occasionally  the  tonsils  become  the  seat  of  the  growth  of  a 
fungus  known  as  leptothrix ;  the  base  of  the  tongue  may  also  be  affected.  The 
affected  areas  are  dotted  here  and  there  with  small  plaques,  of  white  or  yellow 
material,  composed  of  flat  epithelial  cells  and  masses  of  interlacing  threads — 
the  mycelium  of  the  fungus — and  fine  granular  matter  representing  the  spores. 
The  presence  of  the  fungus  does  not  usually  give  rise  to  any  signs  of  inflam- 
mation. 

Syphilis  of  the  Tonsils  and  Pharynx. — Chancre  of  the  tonsil  is  one  of  the 
most  frequent  sites  of  extragenital  infection,  both  as  the  result  of  direct  and 
of  mediate  contagion.  Marked  induration  may  or  may  not  be  present;  there 
is  a  distinct  tendency  to  rapid,  sometimes  phagedenic,  ulceration.  The  initial 
lesion  may  thus  be  mistaken  for  a  malignant  growth  of  the  tonsil.  The  cervical 
lymph  nodes  are  markedly  enlarged.  The  secondary  syph  Hides  occur  upon 
the  tonsil,  in  the  form  of  mucous  patches;  the  entire  surface  of  the  tonsil  is 
frequently  involved,  and  is  covered  by  a  white  or  pearl-gray  film  of  exudate, 
surrounded  by  a  red  areola,  often  combined  with  a  general  pharyngitis.  Syph- 
ilitic erythema  of  the  pharynx  and  soft  palate  is  one  of  the  commonest  lesions 


496     INJURIES   AND   DISEASES    OF   THE   MOUTH   AND   THEOAT 

during  the  early  secondary  stage.  It  has  already  been  described.  It  does  not 
materially  differ  from  ordinary  erythema  in  appearance,  except  that,  as  stated, 
an  arch  of  redness  crosses  the  soft  palate,  and  there  are  frequently  mucous 
patches  also  present.  Gummata  of  the  pharynx  are  notably  common.  They 
occur  frequently  in  the  soft  palate,  and  may  lead  to  perforation,  or  extensive 
destruction  and  scarring;  if  multiple,  to  a  sclerosis  of  the  muscular  tissue  of 
the  palate.  Disturbances  of  speech,  a  nasal  voice,  the  regurgitation  of  food 
into  the  nose,  difficulty  in  swallowing,  and  other  disagreeable  symptoms  are 
the  result. 

Erysipelas  of  the  Throat. — Erysipelas  of  the  throat  has  already  been  men- 
tioned. It  is  characterized,  as  already  stated,  by  the  local  and  constitutional 
symptoms  of  erysipelas,  by  a  tendency  to  produce  edema  of  the  glottis,  and 
to  extend  down  the  trachea  and  cause  broncho-pneumonia. 

Tuberculosis  of  the  Pharynx,  Tonsils,  and  Palate. — Tuberculosis  of  the  phar- 
ynx, tonsils,  and  palate  is  extremely  rare  as  a  primary  condition,  and  occurs 
for  the  most  part  as  a  complication  of  advanced  tuberculosis  of  the  lungs.  It 
is,  however,  probable  that  the  tonsils  are  the  avenue  of  infection  in  many  cases 
of  tuberculous  glands  of  the  neck.  The  bacilli  may  pass  through  the  tissue  of 
the  tonsil  and  infect  the  lymph  nodes  without  producing  any  evident  change 
in  the  tonsil  itself ;  and  it  is  believed  that  the  removal  of  hypertrophied  tonsils 
may  prevent  a  recurrence  of  tuberculous  glands  of  the  neck  after  their  oper- 
ative removal.  Tubercular  ulcerations,  if  present,  have  the  characteristic  ap- 
pearances. They  occur  upon  the  soft  palate,  pillars  of  the  fauces,  posterior  wall 
of  the  pharynx,  and  tonsils.  Larger  or  smaller  nodules  are  formed  in  the 
mucous  membrane,  which  break  down  and  form  ragged  ulcers  with  cheesy 
degeneration  of  the  bases ;  submiliary  tubercles  can  be  seen  around  the  ulcer ; 
the  cervical  lymph  nodes  are  usually  tuberculous.  Tuberculosis  rarely  causes 
perforation  of  the  soft  palate,  as  does,  so  commonly,  syphilis.  Tuberculosis  of 
the  hard  palate  occurs  as  a  slowly  progressive  tubercular  caries,  with  final 
perforation.     As  compared  with  syphilis  it  is  very  infrequent. 

Stenoses  and  Cicatricial  Adhesions  in  the  Pharynx. — The  syphilitic  tertiary 
ulcerations  of  the  hard  and  soft  palate  and  of  the  pharynx  are  sometimes  ex- 
tensive and  destructive.  During  the  healing  process  there  may  be  adhesions 
formed  between  the  posterior  surface  of  the  soft  palate  and  the .  posterior 
pharyngeal  Avail,  and  also  stenosis  of  the  pharynx.  Similar  cicatricial  con- 
tractions may  follow  burns  and  the  ingestion  of  caustic  liquids.  In  addition 
to  strictures  of  the  pharynx  and  adhesions  between  the  soft  palate  and  the 
pharyngeal  wall  there  may  be  adhesions  between  the  soft  palate  and  the  base 
of  the  tongue.  The  adhesions  between  the  soft  palate  and  the  pharyngeal  wall 
diminish,  or  less  commonly  entirely  occlude  the  communication  between  the 
nasopharynx  and  the  pharynx  proper ;  as  a  result,  speech  is  seriously  interfered 
with  in  several  ways.  Moreover,  these  patients  are  usually  obliged  to  breathe 
through  the  mouth,  and  have  little  or  no  sense  of  smell ;  they  may  also  have 
serious  difficulty  in  keeping  the  cavity  of  the  nose  clean.     If,  as  often  happens, 


THE   PALATE,   TONSILS,   AND   PHARYNX  497 

the  closure  is  incomplete,  and  yet  on  account  of  cicatricial  hardening  of  the 
muscles  the  opening  between  the  nose  and  the  pharynx  cannot  be  completely 
closed,  a  portion  of  the  liquids  swallowed  passes  into  the  nose.  The  cicatricial 
strictures  of  the  pharynx  proper  are  of  course  never  complete,  else  the  patient 
would  starve  to  death.  They  may,  however,  be  quite  narrow;  swallowing  may 
be  difficult  and  speech  is  interfered  with.  Each  case  has,  of  course,  a  deformity 
peculiar  to  itself,  and  not  difficult  to  recognize. 

Varicose  Veins. — Varicose  veins  occasionally  occur  in  the  pharynx  and  at 
the  base  of  the  tongue,  and  hemorrhage  from  these  may  lead  to  a  diagnosis  of 
bleeding  from  the  stomach  or  from  the  lungs. 

Tumors  of  the  Palate,  Pharynx,  and  Tonsils. — Among  the  tumors  of  the  palate 
are  fibroma,  sarcoma,  and  occasionally  dermoid  cysts.  Carcinoma  of  the  hard 
and  soft  palate  is  nearly  always  due  to  the  spread  of  a  carcinoma  from  neigh- 
boring structures.  Mucous  polypi  and  papillomata,  and  occasionally  adenomata, 
are  observed.  Some  of  the  polypi  consist  of  adenoid  tissue  resembling  the 
structure  of  the  tonsil ;  others  are  covered  with  horny  integument  and  with 
hair.  The  hairs  may  be  few  and  fine  or  thick  and  numerous,  and  quite  long. 
These  hairy  polypi  usually  grow  from  the  wall  of  the  pharynx.  They  are 
regarded  as  teratomata  by  some  observers,  by  others  as  dermoids.  The  papil- 
lomata are  sessile  or  pedunculated,  with  a  pedicle  which  grows  longer  with 
time.  Cavernous  hemangiomata  sometimes  occur  in  the  soft  palate.  The 
angiomata,  when  of  large  size,  are  dangerous  from  accidental  hemorrhage. 
Combinations  with  lymphangioma  also  occur.  Fibroma,  myoma,  myxoma, 
lipoma,  and  sarcoma  have  been  described  as  originating  in  the  palate. 

Mixed  Tumors. — Mixed  tumors  may  occur  in  the  soft  palate  in  various 
combinations.  They  contain  cartilage,  epithelial  elements  in  the  form  of  ade- 
noma or  epithelioma,  fibrous  tissue,  and  mucous  tissue;  there  may  be  areas  of 
sarcomatous  round  or  spindle  cells.  These  tumors  sometimes  occur  alone,  and 
sometimes  are  directly  connected  with  similar  growths  in  the  parotid  gland. 
They  are  benign  tumors  at  first,  but  may  undergo  ulceration,  and  resemble 
closely  a  gummatous  ulcer,  with  putrid  decomposition  and  a  fetid  breath.  They 
may  also  undergo  carcinomatous  degeneration.  They  form  small  solid  or 
partly  cystic  tumors,  and,  if  not  ulcerated,  are  movable  beneath  the  mucous 
membranes.  Very  rarely  cystic  tumors  occur  in  the  soft  palate,  lined  with 
ciliated  epithelium. 

Tumors  of  the  Tonsil. — The  tumors  of  the  tonsil  are  chiefly  carcinoma 
and  sarcoma.  They  are,  generally  speaking,  rapidly  growing  and  very  malig- 
nant tumors,  having  the  characters  already  described  as  appertaining  to  these 
new  growths.  They  show  an  early  tendency  to  ulceration.  Their  very  early 
recognition  is  essential  to  any  hope  of  cure.  The  surest  method  of  diagnosis 
is  the  removal  of  a  fragment  of  the  growth  for  a  microscopic  examination. 

Adenoid  Tumors. — Adenoid  tumors  of  the  vault  of  the  pharynx  produce 

the  symptoms  already  described  under  Hypertrophy  of  the   Tonsils.      Their 

presence  is  readily  detected  by  palpation,  less  easily  by  posterior  rhinoscopv. 
33 


498    INJURIES   AND   DISEASES    OF   THE   MOUTH   AND   THROAT 

They  may  be  hard  or  soft,  so  large  as  to  nearly  fill  the  nasopharynx  or  so 
small  as  to  produce  no  symptoms.  They  commonly  grow  from  the  vault,  or 
top,  of  the  pharynx,  less  commonly  from  the  posterior  wall,  or  from  both 
situations. 

The  Fibrous  Tumors  of  the  Nasopharynx.  Fibrous  Polypus — Naso- 
pharyngeal Fibroma. — These  tumors  grow  chiefly  from  the  fibro-cartilage, 
between  the  occipital  and  the  sphenoid  bones.  They  occur  most  often  in  males, 
between  the  ages  of  fifteen  and  twenty-five  years.  They  are  hard,  fibrous 
tumors,  covered  with  mucous  membrane,  and  consist  of  bundles  of  fibrous 
tissue  with  few  cells.  When  inflammation  occurs  in  the  tissue  of  the  tumor, 
as  often  happens,  and  abundant  round-celled  infiltration,  the  dense,  fibrous 
structure  may  be  obscured  and  the  microscopic  appearances  so  changed  that 
the  tumor  may  be  taken  for  a  round-celled  sarcoma.  Although  these  tumors 
are  so  far  benign  that  they  form  no  metastases,  yet,  in  their  local  destructive 
effects  from  pressure  and  rather  rapid  growth,  in  their  spread  into  the  nasal 
fossa?  and  the  accessory  cavities  of  the  face,  in  their  invasion  of  the  cranial 
cavity,  and  other  characters,  they  constitute  a  dangerous  and  often  fatal  dis- 
ease. Beginning,  as  stated,  in  the  base  of  the  skull,  these  tumors  grow  down- 
ward into  the  upper  pharynx.  In  some  cases  they  reach  only  a  moderate 
size,  and  then  cease  growing;  in  others  they  exhibit  an  extraordinarily  active 
growth,  and  may  recur  after  extirpation.  They  possess  the  peculiarity  of 
invading  the  several  cavities  of  the  face  steadily  and  progressively,  and  of 
causing  the  destruction  or  absorption  of  the  normal  structures  in  their  path, 
chiefly  by  pressure. 

The  early  symptoms  observed  are,  first,  obstruction  of  the  nose  upon  one 
side,  to  which  is  added  an  increased  secretion  of  mucus  or  muco-pus — the 
symptoms,  namely,  of  nasal  catarrh.  The  other  nostril  soon  becomes  plugged. 
The  tumor  advances  into  the  nasal  fossa3,  and  invades  and  occupies,  one  after 
the  other,  the  accessory  cavities  of  the  nose — the  antrum,  the  ethmoidal  cells, 
sometimes  the  frontal  sinus — and  grows  downward  and  backward  into  the 
pharynx.  The  walls  of  the  bony  cavities  are  gradually  destroyed  and  absorbed 
by  pressure.  From  the  cells  of  the  ethmoid  they  may,  although  rarely,  invade 
the  orbit.  Penetration  into  the  cranial  cavity  and  the  formation  of  an  intra- 
cranial growth  is  not  uncommon.  After  the  tumor  has  reached  a  certain  size, 
various  deformities  result.  The  skeleton  of  the  nose  is  forced  apart  so  that 
the  nose  is  broadened  and  flattened.  Absorption  of  the  anterior  wall  of  the 
antrum  causes  a  bulging  of  the  cheek.  Invasion  of  the  temporal  fossa,  a 
prominence  in  the  temporal  region  above  or  below  the  zygoma.  Interference 
with  nasal  breathing  causes  the  patient  to  keep  his  mouth  open.  Exophthalmos 
results  from  invasion  of  the  orbit.  The  symptoms  of  interference  with  the 
cranial  nerves,  notably  with  vision,  are  rare  until  the  last  stages  of  the  disease, 
and  are  much  more  common  in  the  case  of  malignant  growths.  One  of  the 
characteristic  symptoms  of  the  disease  is  hemorrhage,  which  proceeds  from 
superficial  ulcerations  on  the  surface  of  the  tumor,  notably  in  the  pharynx. 


THE   PALATE,   TONSILS,   AXD   PHARYNX  499 

The  hemorrhages  may  be  moderate  or  severe ;  they  are  often  repeated  upon 
slight  causes  of  irritation,  such  as  coughing,  sneezing,  straining,  etc.,  or  they 
may  occur  spontaneously ;  they  may  be  of  a  dangerous  or  even  fatal  character. 
Septic  infection  of  the  ulcerated  surfaces  of  the  tumor  causes  a  purulent  dis- 
charge, general  symptoms  of  intoxication,  sometimes  a  fetid  breath. 

The  signs  observed  upon  inspection  and  'palpation  vary  with  the  age  and 
size  of  the  growth.  The  tumors  may  merely  occupy  a  portion  of  the  naso- 
pharynx. More  commonly  the  patient  does  not  come  under  the  observation 
of  the  surgeon  until  the  tumor  has  reached  a  considerable  size.  The  pharynx, 
and  often  the  cavity  of  the  nose,  will  then  be  found  filled  with  a  firm,  dense 
mass  ;  the  surface,  when  viewed  through  the  nose  or  by  posterior  rhinoscopy, 
may  be  white  or  bluish-gray  or  pink  in  color ;  large  veins  can  sometimes  be 
seen  upon  its  surface.  In  the  pharynx  ulceration  of  the  tumor  surface  is 
common.  It  will  then  appear  yellow  or  brown  in  color,  or  covered  with  crusts. 
The  tumor  feels  firm  and  elastic,  and  bleeds  readily  on  mechanical  irritation. 
Although  the  main  tumor  of  the  pharynx  is  often  firmly  packed  into  the  pharyn- 
geal vault,  a  little  mobility  upon  palpation  is  not  uncommon.  The  finger  or 
a  probe  can  sometimes  be  passed  up  behind  the  tumor,  and  its  probable  attach- 
ment to  the  base  of  the  skull  may  be  thus  inferred.  The  differential  diagnosis 
between  fibroma  of  this  type  and  malignant  growths  depends  in  part  upon 
the  age  and  sex  of  the  patient,  upon  the  absence  of  infiltration  characteristic 
of  sarcoma  and  carcinoma,  upon  the  fact  that  the  ulceration  remains  super- 
ficial, sometimes  upon  the  recognition  of  mobility,  sometimes  only  upon  micro- 
scopic examination.  In  general,  it  may  be  said  that,  although  these  tumors 
grow  rapidly,  they  do  not  grow  as  fast  as  the  sarcomata,  as  a  rule. 

Tumors  of  the  Lower  Part  of  the  Pharynx. — Very  rarely  lipoma, 
usually  in  the  form  of  lipoma  arborescens,  may  grow  in  the  lower  part  of  the 
pharynx,  at  or  near  the  level  of  the  rima  glottidis.  They  may  interfere  with 
respiration  by  falling  into  the  larynx.  Fibrous  tumors,  often  pedunculated, 
or  even  cylindrical  in  shape,  may  occur  in  the  same  situation.  From  the  pos- 
terior wall  of  the  pharynx  there  may  grow  fibroma,  enchondroma,  or  mixed 
tumors,  usually  distinctly  encapsulated  and  movable.  Prom  their  size  and 
situation  they  may  cause  obstruction  to  breathing  or  to  swallowing.  Accessory 
thyroid  glands  may  occur  in  the  same  situation.  Epithelioma  and  carcinoma 
may  rarely  arise  from  the  posterior  pharyngeal  wall.  I  have  seen  two  such 
cases ;  both  grew  from  the  posterior  wall  of  the  pharynx,  at  the  level  of  the 
upper  border  of  the  larynx.  One  was  a  somewhat  flattened  ulcerated  nodule, 
of  about  the  size  of  an  English  walnut,  which  had  caused  pain  and  difficulty 
in  swallowing,  together  with  slight  dyspnea.  The  patient  was  a  woman  of 
middle  age ;  the  tumor  was  an  epithelioma  of  the  flat  epithelial-celled  type. 
The  second  case  occurred  in  a  man  fifty-two  years  of  age,  in  the  same  situation. 
It  was  of  about  the  same  size  as  in  the  former  case,  but  was  a  cauliflowerlike 
growth,  which  hung  forward  over  the  entrance  to  the  larynx.  Both  tumors 
were  reached  without  much  difficulty  through  a  subhyoid  pharvngotomy. 


500     INJURIES    AND   DISEASES    OF   THE   MOUTH   AND   THROAT 

These  two  cases  were  operated  upon  by  Dr.  Charles  McBurney  in  the 
Roosevelt  Hospital. 

Sarcomata  of  several  types  have  occasionally  been  observed  in  the  same 
situation.  Carcinomata  may  also  develop,  posterior  to  or  to  one  side  of  the 
larynx.  They  are  generally  more  or  less  circular  tumors,  surrounding  the  lar- 
ynx, which  soon  invade  the  larynx  itself.  They  are  apt  to  cause  early  dis- 
turbances in  swallowing,  and  are  not  easy  to  recognize  except  by  deep  palpation ; 
an  ordinary  laryngoscopic  view  is  not  sufficient ;  sometimes  an  ulcerated  sur- 
face can  be  observed  behind  the  larynx.  They  are  as  a  rule  very  malignant 
tumors,  of  bad  prognosis.  Carcinoma  and  sarcoma  may  occur  in  the  vault  and 
in  the  sides  of  the  pharynx,  especially  in  the  tonsils.  They  give  rise  very  early 
to  serious  disturbances,  to  ulceration,  hemorrhages,  a  fetid  breath,  disturbances 
of  breathing  and  swallowing.  They  are  rarely  recognized  at  a  time  when  their 
operative  removal  is  possible,  except  those  tumors  which  arise  in  the  tonsil 
itself. 


CHAPTER    XVII 


INJURIES   AND   DISEASES   OF   THE   EAR 


THE   EXTERNAL    EAR 


Congenital  Defects. — Various  congenital  deformities  occur  in  the  external 
ear.  They  are,  for  the  most  part,  easily  recognized  on  inspection.  Some  of 
them  may  properly  be  mentioned.  The  entire  pinna  or  auricle  may  very  rarely 
be  absent,  or  more  commonly  imperfect  in  one  or  other  of  its  parts,  or  crumpled, 
or  the  ears  may  stand  out  at  right  angles  to  the  head.  The  ears  may  be 
abnormally  small  or  large; 
the  latter  condition  is  often 
combined  with  mental  weak- 
ness, with  criminality  or 
idiocy.  There  may  be  two 
or  more  auricles.  There 
may  be  stenosis,  or  atresia 
of  the  external  auditory 
canal.  Incomplete  closure 
of  the  first  branchial  cleft 
may  leave  a  fistulous  tract, 
usually  one  half  or  three 
quarters  of  an  inch  in  front 
of  and  above  the  tragus; 
occasionally  in  the  lobule 
or  in  other  parts  of  the  ear. 
These  fistulaa  are  usually 
not  deep ;  they  may,  on  the 
other  hand,  communicate 
with    the    pharynx.       They 

commonly  secrete  a  little  yellowish  fluid.  Auricular  appendages  occur  in  front 
of  the  ear  as  small,  sessile,  or  pedunculated  masses  of  skin  and  fibrous  tissue ; 
they  may  contain  a  fragment  of  cartilage.  The  lobule  of  the  ear  may  be  fissured 
as  a  congenital  condition  or  as  the  result  of  traction  by  heavy  earrings. 

Injuries  of  the  Ear. — Wounds  of  the  ear,  both  subcutaneous  and  open  and 
of  all  kinds,  occur  not  infrequently.  The  vascularity  of  the  ear  is  great,  and 
such  wounds  heal,  as  a  rule,  rapidly  and  well.     Severe  contusions  of  the  ear 

501 


Fig.  177. — Congenital  Deformity  of  the  Ear. 


502 


INJURIES   AND   DISEASES    OF   THE   EAE 


may  be  accompanied  by  fracture  of  the  cartilages  and  by  hematoma  of  con- 
siderable size  between  the  perichondrium  and  the  cartilage.  The  hematoma 
forms  a  bluish-red,  fluctuating  swelling,  usually  most  prominent  in  the  side 
of  the  ear  next  the  head,  less  marked  upon  the  outer,  or  concave,  side  of  the 
ear.     The  blood  in  the  former  situation  is,  however,  more  rapidly  absorbed, 

and  therefore  the  latter  remains 
longer.  Infection  of  the  hematoma 
may  lead  to  purulent  perichondri- 
tis and  loss  of  portions  of  cartilage 
with  crumpled  deformity.  Boxers, 
football  players,  and  acrobats  some- 
times have  this  deformity  {fighter's 
ear). 

The  Insane  Ear. — Among  in- 
sane persons — notably  those  suffer- 
ing from  paralytic  dementia,  but 
also  in  other  forms  of  insanity,  and 
rarely  even  among  healthy  persons 
— a  spontaneous  hematoma  may 
form  in  the  external  ear.  The  tu- 
mor forms  in  the  course  of  a  few 
days,  sometimes  with  inflammatory 
symptoms.  Subsequent  enlarge- 
ment and  thickening  or  crumpled 
deformity  of  the  ear  results.  De- 
generative changes  in  the  cartilages  and  atheroma  of  the  blood-vessels  are 
present  in  these  cases. 

Keloid. — The  frequent  occurrence  of  keloid  in  the  lobule  of  the  ear  has 
already  been  noted  under  tumors.  The  condition  is  most  commonly  observed 
among  negro  women.     (See  Tumors.) 

Perichondritis  of  the  Cartilages  of  the  Ear. — Perichondritis  of  the  cartilages 
of  the  ear  is  a  rare  condition.  It  is  attended  by  swelling  of  the  ear,  sometimes 
with  pain,  acute  inflammation,  and  the  formation  of  an  abscess,  more  often 
not.     If  suppuration  occurs,  fistulous  tracts  often  remain  for  many  months. 

Tumors  of  the  External  Ear. — Angioma  occurs  upon  the  ear  as  angioma 
simplex,  or  as  a  part  of  a  cirsoid  aneurism  of  the  scalp.  Sarcoma  is  rare. 
Epithelioma  of  the  superficial  or  infiltrating  variety  is  common.  Dermoid 
cysts  may  occur  either  in  front  of  or  behind  the  ear,  and  sebaceous  cysts, 
usually  of  the  posterior  surface  of  the  auricle,  are  not  rare. 

Atresia. — Atresia  of  the  external  auditory  meatus  may  be  complete  or  par- 
tial; if  congenital,  it  is  usually  associated  with  imperfect  development  of  the 
organ  of  hearing.  The  acquired  forms  may  be  of  any  extent  from  a  superficial 
ring-shaped  contraction  to  complete  obliteration  of  the  canal;  no  special  diag- 
nostic signs  can  be  given. 


Fig.  178.  —  Boxer's  Enchondroma  (Fighter's 
Ear).  Photograph  of  J.  F.,  pugilist,  aged  thirty- 
four. 


THE  EXTERNAL   EAR  503 

Wounds  of  the  External  Auditory  Canal. — Wounds  of  the  external  auditory 
canal  are  not  generally  dangerous  unless  they  involve  the  tympanic  membrane 
or  the  posterior  wall  of  the  bony  canal,  or  become  infected.  Fracture  of  the 
anterior  wall,  from  blows  upon  the  chin,  has  been  spoken  of  under  Dislocations 
of  the  Jaw,  and,  as  was  there  stated,  the  condyle  of  the  jaw  has  been  driven 
upward  through  the  bone,  into  the  middle  fossa  of  the  skull,  by  extreme  degrees 
of  violence.  Fractures  of  the  posterior  wall  of  the  canal  occur  most  often  with 
fractures  of  the  base  of  the  skull  through  the  middle  fossa ;  the  signs  and 
symptoms  have  been  fully  described  under  Fractures  of  the  Base.  The  diag- 
nosis of  fractures  of  the  anterior  wall  of  the  bony  canal  is  to  be  made  from 
the  history  of  a  fall  or  blow  upon  the  chin,  the  presence  of  hemorrhage  from 
the  external  meatus,  and  the  deformity,  recognizable  by  examining  the  external 
auditory  canal  with  a  speculum  or  a  probe,  or  both,  after  washing  away  the 
blood  with  sterile  salt  solution.  Very  serious  and  even  fatal  injuries  may  be 
caused  by  the  accidental  or  intentional  introduction  of  caustic  liquids  or  of 
molten  metal  into  the  ear.  The  diagnosis  is  to  be  made  from  the  history, 
from  the  very  severe  pain,  from  the  evidences  of  a  burn,  or  from  inflammation, 
or  the  presence  of  a  mass  of  metal  together  with  a  burn  in  the  external  auditory 
canal.  If  the  material  has  entered  the  middle  ear,  there  is  usually,  also,  total 
deafness. 

Furuncle  of  the  External  Auditory  Canal. — Furuncle  of  the  external  auditory 
canal  occurs  as  the  result  of  digging  in  the  ears  with  unclean  instruments;  as 
a  secondary  process  following  the  discharge  of  pus  from  the  middle  ear,  or 
without  apparent  cause.  There  may  be  but  one  furuncle,  or  a  series  of  them 
occur,  one  after  the  other.  When  the  furuncle  is  situated  close  to  the  external 
auditory  meatus  it  may  usually  be  seen  without  difficulty;  when  it  is  more 
deeply  seated,  the  general  swelling  of  the  skin  lining  the  canal  is  usually  so 
great  that  it  is  hard  to  examine  the  deeper  portions  of  the  canal.  The  pain 
of  these  furuncles  is  extreme,  and  is  of  a  throbbing,  intense  character,  worse  at 
night.  Rupture  of  the  furuncle  is  followed  by  a  discharge  of  pus  from  the 
ear  and  relief  of  the  pain,  but  other  furuncles  are  apt  to  form,  when  the  severe 
pain  will  return.  A  thorough  examination  of  the  ear  of  these  patients  with 
a  speculum  is  practically  impossible  without  a  general  anesthetic.  Cocain  has 
been,  in  my  experience,  ineffective. 

Diffuse  Inflammation  of  the  External  Auditory  Canal. — Diffuse  inflammation 
of  the  external  auditory  canal  may  occur  of  any  degree  of  severity  from  a  slight 
redness  and  swelling  up  to  a  severe  phlegmonous  inflammation,  with  involve- 
ment of  the  periosteum.  A  bad  form  of  this  condition  is  not  infrequent  in 
the  course  of  diabetes,  and  a  diffuse  inflammation  in  this  region  should  lead 
to  an  examination  of  the  urine  for  sugar.  If  the  tissues  are  greatly  swollen, 
it  will  be  impossible  to  introduce  a  speculum  and  examine  the  tympanic  mem- 
brane, and  thereby  exclude  inflammation  of  the  middle  ear.  In  some  cases 
the  swelling  and  redness  will  extend  to  the  skin  covering  the  mastoid  process. 
The  subjective  symptoms  of  inflammation  of  the  external  auditory  canal  merely, 


504  INJURIES   AND   DISEASES    OE   THE   EAE 

are  pain,  noises  in  the  ear,  and  partial  deafness ;  but  unless  the  canal  is  en- 
tirely occluded  by  the  swelling,  the  deafness  will  be  much  less  marked  than  is 
the  case  with  inflammation  of  the  middle  ear.  The  ear  may  be  very  carefully 
washed  out  with  warm  sterile  salt  solution,  and  if  the  deafness  then  disappears, 
inflammation  of  the  middle  ear  is  excluded.  Swelling  of  the  preauricular 
lymph  nodes  favors  the  diagnosis  of  inflammation  of  the  external  ear.  Swell- 
ing of  a  lymph  node  over  or  behind  the  mastoid  process  indicates  inflamma- 
tion of  the  middle  ear.  Moreover,  the  swelling  of  the  skin  in  otitis  externa 
is  more  marked  than  that  of  the  deeper  tissues ;  the  groove  between  the  ear  and 
the  mastoid  process  is  often  obliterated.  Periostitis  of  the  mastoid  process  is 
accompanied  by  swelling  of  the  periosteum  rather  than  of  the  skin.  The  groove 
usually  remains  discernible.  The  phlegmonous  variety  of  inflammation  may 
be  attended  with  severe  septic  symptoms,  involvement  of  the  periosteum  and 
bone,  sinus  phlebitis,  meningitis,  and  pyemia. 

Accumulated  Cerumen  (Ear  Wax)  in  the  External  Auditory  Canal. — Accu- 
mulated cerumen  in  the  external  auditory  canal  may  cause  partial  deafness  if 
it  entirely  fills  the  caliber  of  the  canal,  ringing  in  the  ears,  a  sensation  of  itch- 
ing, of  a  foreign  body  in  the  ear,  sometimes  giddiness.  These  plugs  of  wax 
can  sometimes  be  seen  as  dark-brown,  almost  black,  masses  by  placing  the 
patient  so  that  a  strong  light  falls  into  the  ear,  and  by  drawing  the  external 
ear  upward,  outward,  and  backward,  or  by  the  introduction  of  an  ear  speculum, 
and  illuminating  the  interior  of  the  ear  by  natural  or  artificial  light  reflected 
into  the  ear  from  a  suitable  concave  mirror. 

Foreign  Bodies  in  the  External  Ear. — Foreign  bodies  of  the  most  varied 
description  may  be  introduced  into  the  external  auditory  canal,  either  by  acci- 
dent or  design.  The  majority  of  these  patients  are  children.  The  bodies  usu- 
ally remain,  if  let  alone,  in  the  cartilaginous  portion  of  the  canal,  unless,  as  is 
rarely  the  case,  they  are  maggots,  fleas,  flies,  or  other  live  creatures,  which 
may  find  their  way  beyond  the  narrowest  portion  of  the  canal  at  the  junction 
of  the  cartilaginous  and  bony  sections.  Unskillful  efforts  at  removal  may 
cause  wounds  of  the  tympanic  membrane ;  or  the  foreign  body  may  be  forced 
into  the  middle  ear.  The  presence  of  a  foreign  body  may  cause  no  symptoms 
at  all ;  or,  if  it  rests  against  the  tympanic  membrane,  it  may  cause  ringing  in 
the  ear  or  giddiness ;  if  it  fills  the  canal,  it  will  cause  partial  deafness.  In 
some  cases  a  foreign  body,  if  infected,  may  cause  inflammation,  attended  by 
pain,  swelling,  and  a  discharge  from  the  ear.  The  presence  of  insects,  if  alive, 
will  cause  noises  in  the  ear,  sometimes  pain  and  giddiness.  The  presence 
of  a  foreign  body  in  the  ear  is  determined  by  inspection,  either  direct  or  through 
a  speculum.     The  diagnosis  is  usually  not  difficult. 

TYMPANIC    MEMBRANE 

Injuries  of  the  Tympanic  Membrane. — The  tympanic  membrane  may  be  in- 
jured by  direct  or  indirect  violence.     The  injuries  from  direct  violence  are 


TYMPANIC   MEMBRANE  505 

caused  by  the  introduction  of  sliarp-pointed  instruments  into  the  ear — sharp 
sticks,  etc. — or  occur  from  unskillful  efforts  to  extract  foreign  bodies.  The 
injuries  by  indirect  violence  are  caused  by  blows  and  falls  upon  the  head,  by 
sudden  changes  in  the  atmospheric  pressure  in  the  external  auditory  canal, 
as  from  a  box  on  the  ear,  diving  in  deep  water,  working  in  caissons,  fractures 
of  the  base  of  the  skull,  the  near  discharge  of  large  cannon,  etc.  The  symp- 
toms and  signs  of  rupture  of  the  tympanic  membrane  are  partly  subjective 
and  partly  objective.  The  subjective  symptoms  are  pain  in  the  ear,  sometimes 
giddiness,  sometimes  faintness  and  vomiting;  there  is  partial  deafness.  If  the 
injury  has  been  caused  by  direct  violence,  the  labyrinth  may  be  injured. 

The  symptoms  of  injuries  of  the  labyrinth  are  sudden  marked  giddiness, 
nausea,  and  vomiting.  At  the  moment  of  the  injury  the  patient  usually  has 
the  subjective  sensation  of  a  loud  sound.  The  symptoms  of  cerebral  shock  are 
often  present.  The  subsequent  symptoms  are  giddiness,  difficulty  in  maintain- 
ing equilibrium,  sometimes  a  staggering  gait.  The  patient  grasps  surrounding 
objects  to  steady  himself,  and  for  several  weeks  may  suffer  from  vertigo  and 
nausea,  whenever  he  tries  to  stand  or  sit  up.  In  injuries  of  the  labyrinth  deaf- 
ness will  be  marked,  and  is  usually  complete  in  the  affected  ear. 

The  immediate  diagnosis  of  ruptures  of  the  tympanic  membrane,  while 
it  may  usually  be  inferred  from  the  history,  the  bleeding,  and  other  signs  and 
symptoms  already  described,  is  not  always  capable  of  verification.  The  exter- 
nal auditory  canal  is  usually  filled  with  a  mixture  of  fluid  and  clotted  blood, 
and  the  tympanum  cannot  be  inspected  until  this  is  removed.  It  would  be 
unwise  under  these  conditions  to  clear  the  canal  with  a  syringe  and  warm  water, 
because  of  the  danger  of  forcing  infectious  material  into  the  middle  ear.  The 
blood  may,  however,  be  gently  wiped  away  with  small  pieces  of  sterile  cotton 
or  gauze.  The  ear  drum,  when  exposed,  will  often  show  extensive  ecchymosis 
into  its  substance.  The  seat  of  the  rupture  will  appear  as  an  ecchymotic  spot, 
or  streak,  in  the  membrane,  or  there  may  be  a  ragged  tear  filled  with  blood  clot. 
The  membrane  near  the  rupture  will  be  the  seat  of  ecchymosis,  more  or  less 
widespread.  The  rupture  may  be  in  any  part  of  the  membrane,  but  is  more 
commonly  in  the  lower  half.  There  is  usually  but  one  perforation,  although 
there  may  be  several.  Ruptures  by  indirect  violence  are  rarely  followed  by 
infection.  Those  caused  by  direct  violence  with  unclean  instruments  may  be 
followed  by  suppurative  inflammation  of  the  middle  ear. 

The  medico-legal  question  is  sometimes  raised  as  to  whether  deafness,  fol- 
lowing an  injury  to  the  ear,  is  due  to  the  accident  itself,  or  to  antecedent  dis- 
ease of  the  ear.  This  question  can  sometimes  be  answered,  very  often  it  cannot. 
If  the  patient  can  be  examined  soon  after  the  alleged  injury,  ecchymosis  in  the 
tympanic  membrane,  and  the  absence  of  the  signs  of  a  chronic  inflammatory 
lesion  of  the  middle  ear,  speak  for  a  traumatic  origin.  An  extensive  well- 
rounded  loss  of  substance  in  the  tympanic  membrane,  with  thickening,  a  purulent 
discharge  from  the  ear,  will  point  rather  to  antecedent  disease  of  the  middle  ear. 
Infection  may,  however,  have  followed  the  injury,  and  in  many  cases  it  will 


506  INJURIES   AND   DISEASES    OE   THE   EAR 

be  impossible  to  say  whether  or  not  the  condition  is  due  to  the  accident  or  to 
antecedent  disease. 

EXAMINATION    OF    THE    EAR 

Although  the  diseases  of  the  ear  are,  at  the  present  time,  almost  exclusively 
in  the  hands  of  specialists,  a  brief  description  of  the  methods  used  in  examin- 
ing the  ear  seems  necessary  in  this  place.  The  methods  of  examination  are: 
By  direct  inspection  of  the  external  auditory  canal ;  inspection  of  the  canal 
and  of  the  tympanic  membrane  through  a  speculum  (otoscopy)  ;  catheterization 
of  the  Eustachian  tube ;  further,  the  procedures  of  Politzer  and  Valsalva ;  the 
diagnostic  auscultation  of  the  ear  with  the  auscultation  tube;  finally,  testing 
of  the  hearing. 

Direct  Inspection  of  the  External  Auditory  Ganal. — The  examination  of  the 
external  auditory  canal  is  conducted  by  daylight  or  by  artificial  light.  Day- 
light is  preferable  because  the  normal  color  of  the  tympanic  membrane — a  pearl 
gray,  with  a  tinge  of  bine — is  perceived ;  by  gaslight  or  electric  light,  it  appears 
yellow,  with  a  tinge  of  red.     A  head  or  hand  mirror,  concave,  perforated  at  the 


ooo  kOOQ 


Fig.  179. — Geubee's  Aural,  Speculum.  Fig.  180. — Politzer 's  Hard-Rubber  Aural 

Speculum. 

center,  and  two  inches  and  three  fourths  in  diameter  and  a  focal  distance  of 
six  inches,  is  generally  used  to  cast  reflected  lights  into  the  ear.  The  mirror 
may  be  held  in  the  hand,  or  an  ordinary  laryngoscopic  head  mirror  may  be 
substituted,  and  worn  on  the  forehead ;  or  one  or  other  of  the  small  electric 
headlights  in  common  use  may  be  used,  if  convenient.  The  source  of  illumina- 
tion may  be  daylight — preferably  with  a  northern  exposure;  a  bull's-eye  with 
an  Argand  burner ;  or  an  electric-light  bulb ;  or  the  electric  headlight,  as  stated. 
Direct  sunlight  is  undesirable. 

Inspection  of  the  Canal  and  of  the  Tympanic  Membrane  through  a  Speculum. 
— Two  varieties  of  specula  are  in  common  use — that  of  Gruber,  made  of  metal 
and  elliptical  on  section,  and  that  of  Politzer,  made  of  hard  rubber  and  circu- 
lar on  section.  They  are  made  usually  in  three  sizes.  Further,  in  order  to 
determine  the  mobility,  and  some  other  qualities  of  the  tympanic  membrane, 
some  modification  of  Siegel's  pneumatic  otoscope,  or  Brunton's  otoscope,  may 
be  used.  These  instruments  consist,  essentially,  of  a  small  air-tight  box  of  hard 
rubber  or  metal  attached  to  an  ear  speculum.  The  interior  of  the  box  is  con- 
nected with  a  rubber  tube  and  hand  bulb.  In  one  side  of  the  box  there  is  a 
glass  window  or  lens.     The  speculum  of  the  apparatus  being  introduced  into 


EXAMINATION    OF   THE   EAR  507 

the  external  auditory  canal,  the  surgeon  may  examine  the  tympanic  membrane 
through  the  window,  and  by  means  of  the  hand  bulb  connected  with  the  appa- 
ratus the  air-pressure  upon  the  membrane  may  be  increased  or  diminished, 
causing  it  to  move  back  and  forth,  and  become  more  concave  or  convex,  as  the 
case  may  be.  Its  degree  of  mobility,  normal  or  abnormal ;  the  presence  of 
adhesion;  of  atrophy;  rigidity,  etc.,  may  thus  be  noted  under  the  control  of  the 
eye.  A  good  instrument  of  this  kind  is  now  made  by  the  "  Electro-Surgical 
Instrument  Company,"  of  Rochester,  N.  Y.  In  order  to  insert  the  ear  specu- 
lum properly  the  canal  must  be  made  straight  by  drawing  the  external  ear 
upward  and  backward ;  a  sjDeculum  of  suitable  size  is  then  inserted  very  gently 
into  the  canal,  until  it  has  passed  the  junction  of  the  bony  and  cartilaginous 
portions,  when  it  will  sometimes  stay  of  itself;  or  the  surgeon  may  continue 
the  traction  upon  the  auricle,  upward  and  backward,  with  the  third  and  fourth 
fingers  of  his  band,  while  holding  the  speculum  between  his  forefinger  and 
thumb. 

If  the  ear  contains  epithelial  masses  or  wax,  which  obstruct  the  view,  they 
must  be  washed  out  by  a  stream  of  warm  sterile  salt  solution  or  boric  acid, 
directed  obliquely  upward  against  the  wall  of  the  canal  by  means  of  a  large 
hand  syringe.  The  washing  must  be  done  gently,  else  the  patient  may  suffer 
from  giddiness,  or  even  faintness.  The  ear  is  then  carefully  dried  with  bits  of 
sterile  cotton  or  gauze,  held  in  the  angular  ear  forceps,  and  the  speculum  rein- 
serted. Very  hard  plugs  of  wax  sometimes  resist  efforts  to  wash  them  out. 
If  the  operator  is  skillful,  such  may  be  removed  by  a  scoop,  curette,  or  forceps. 
If  not,  it  is  best  to  soften  the  plug  by  dropping  into  the  ear  a  warm  saturated 
solution  of  sodium  bicarbonate  containing  a  little  glycerin.  Repeated  appli- 
cations may  suffice  in  the  course  of  half  an  hour  to  soften  the  plug  sufficiently 
so  that  it  can  then  be  washed  away.  In  some  instances  it  may  be  necessary 
to  leave  the  alkalin  solution  in  the  ear  overnight  protected  by  a  plug  of  cotton. 

The  normal  eardrum  is,  as  stated,  of  a  pearl-gray  color  when  viewed  by 
daylight,  with  a  slightly  bluish  cast.  By  artificial  light  it  appears  reddish- 
yellow.  The  circumference  of  the  eardrum  is  marked  by  a  white  line.  In 
the  upper  half  of  the  membrane,  extending  from  in  front,  downward  and  back- 
ward, to  the  middle,  is  seen  the  so-called  "  handle  "  of  the  malleus ;  its  short 
process  is  seen  as  a  white  prominence  near  the  upper  and  anterior  border  of 
the  membrane.  In  the  lower  and  anterior  quadrant  is  seen  a  bright  cone-shaped 
area  of  reflected  light,  which  extends  from  the  center  of  the  eardrum,  down- 
ward and  forward,  nearly  to  its  border.  The  surface  of  the  membrane  is  not 
normally  a  plane,  but  exhibits  several  folds  and  cavities.  On  account  of  its 
oblique  position,  and  of  the  concavities,  the  posterior  and  upper  portion  is 
viewed  obliquely;  the  anterior  and  lower  portion  is  more  at  right  angles  to 
the  line  of  vision.  The  eardrum  is  of  varying  degrees  of  transparency,  both 
in  health  and  disease.  Above  the  short  process  of  the  malleus  there  is  a  small 
area  known  as  Shrapnell's  membrane,  or  the  flaccid  portion  of  the  eardrum. 
It  leads  into,  or  forms  a  part  of,  the  floor  of  the  space  known  as  the  epitym- 


508  INJURIES   AND   DISEASES    OE   THE   EAR 

panum.  In  examining  the  tympanum  its  color  should  be  noted,  whether  it 
is  translucent  or  thickened ;  whether  there  are  localized  opacities  or  chalky 
deposits;  whether  the  membrane  bulges,  from  fluid  in  the  middle  ear,  or  is 
retracted.  If  retracted,  the  short  process  of  the  malleus  will  appear  more 
prominent,  the  long  process  will  appear  foreshortened,  and  the  conical  depres- 
sions or  folds,  in  front  of  or  behind  it,  will  appear  deeper,  and  the  light  cone 
may  be  displaced  or  changed  in  shape.  In  order  to  determine  the  mobility 
of  the  membrane,  Siegel's  pneumatic  otoscope  may  be  used,  or  one  of  the  more 
recent  modifications  of  this  instrument. 

Methods  of  Testing  the  Hearing. — In  order  to  test  the  acuteness  of  hearing 
the  ticking  of  a  watch  may  be  used.  The  ears  should  be  alternately  stopped 
by  putting  the  index  finger  in  the  meatus,  and  the  distances  at  which  the 
patient  ceases  to  hear  the  watch  in  each  ear  may  be  alternately  tested  and  com- 
pared ;  or,  the  voice,  either  in  whispered  or  spoken  words,  may  be  used  in  the 
same  way.  The  tuning  fork  may  be  used  to  determine  whether  the  disease 
is  in  the  conducting  apparatus  of  the  middle  ear,  or  in  the  organ  of  hearing  in 
the  labyrinth.  For  this  purpose  a  small  tuning  fork,  usually  in  the  key  of 
"  C,"  vibrating  five  hundred  and  twenty-eight  times  a  second,  is  set  vibrating 
and  held  close  to  the  ear.  Under  normal  conditions  the  note  will  be  heard 
louder  and  longer  in  this  way  than  when  the  base  of  the  fork  is  placed  in 
contact  with  the  mastoid  process — that  is  to  say,  the  aerial  conduction  is  better 
than  the  bony  conduction.  In  deafness  arising  from  the  auditory  canal  or 
from  the  middle  ear,  the  tone  will  be  heard  louder  and  longer  when  the  fork 
is  placed  in  contact  with  the  skull.  When  bone  conduction  is  lost,  it  indicates 
that  the  organ  of  hearing  in  the  labyrinth  is  at  fault,  and  the  same  is  true 
when  the  hearing,  though  imperfect,  is  better  by  aerial  than  by  bone  conduc- 
tion. If  the  handle  of  the  fork  is  introduced  into  the  external  auditory  meatus 
of  one  side,  and  the  patient  hears  the  vibratory  note  only  in  the  opposite  ear, 
we  may  be  sure  that  the  organ  of  hearing  of  the  ear  in  which  the  tuning  fork 
is  placed  is  destroyed. 

Schwartze  gives  this  among  other  methods  for  detecting  simulated  deafness : 
The  healthy  ear  is  plugged  with  cotton  or  with  the  finger ;  if,  then,  the  patient 
states  that  he  does  not  hear  loud,  or  moderately  loud,  spoken  words,  he  exag- 
gerates, or  does  not  speak  the  truth.  The  tuning  fork  may  be  used  in  a  simi- 
lar manner ;  the  sound  ear  may  be  stopped  with  the  finger,  and  the  tuning  fork 
placed  anywhere  upon  the  skull ;  if,  then,  the  patient  says  he  hears  nothing,  he 
is  simulating.  It  is  a  good  plan  in  making  the  various  tests  of  hearing  to 
request  the  patient  to  keep  his  eyes  closed. 

Tests  of  Bony  Conduction  (Weber s  Test,  Rinne's  Test). — Tests  of  bony 
conduction  of  sounds  may  be  made  with  a  watch  or  a  tuning  fork.  In  normal 
cases,  if  the  external  auditory  meatus  be  stopped  on  both  sides  with  the  finger 
tips,  and  a  watch  be  placed  in  contact  with  the  mastoid  process,  the  teeth,  or 
the  temporal  region,  the  ticking  of  the  watch  will  still  be  perceived.  In  cases 
of  partial  deafness  a  positive  result  of  this  experiment  indicates  that  sound 


EXAMINATION   OF   THE    EAR  509 

perceptions  in  the  labyrinth  are  still  present,  although  not  necessarily  perfect. 
Should  the  results  be  negative,  we  cannot  conclude,  from  this  sign  alone,  that 
the  acoustic  nerve  is  paralyzed;  since,  in  persons  over  fifty  years  of  age  and 
in  some  intermittent  functional  disturbances  of  hearing,  the  watch  may  not 
be  heard,  although  the  hearing  may  be  practically  normal  (Politzer).  The 
diagnostic  value  of  the  experiment  is  chiefly  this,  that  if  an  individual  is 
notably  deaf  for  sounds  transmitted  by  aerial  condition,  and  still  hears  the 
ticking  watch  placed  in  contact  with  the  skull  plainly,  he  is  probably  suffering 
from  deafness  due  to  a  disorder  of  the  conducting  apparatus.  If  the  result 
of  the  experiment  is  negative — i.  e.,  the  ticking  not  perceived  by  bony  conduc- 
tion and  the  patient  is  young — it  indicates  a  serious  disturbance  of  hearing,  and 
is  therefore  of  rather  unfavorable  significance   (Pollak). 

Weber's  Test. — If  a  vibrating  tuning  fork  is  placed  in  contact  with  the  skull 
of  an  individual  with  normal  hearing,  the  tone  will  be  either  heard  in  both  ears 
alike  or  referred  to  the  point  of  contact  of  the  fork  with  the  skull.  If,  now, 
one  ear  be  stopped  with  the  finger,  the  sound  will  at  once  be  heard  in  that  ear. 
"  Weber  is  lateralized  on  the  side  where  an  obstruction  exists  in  the  conduct- 
ing apparatus."  If  one  ear  after  the  other  be  stopped,  or  one  more  firmly 
stopped  than  the  other,  the  tone  will  always  be  heard  more  distinctly  in  the 
ear  where  the  greater  obstruction  exists  in  the  conducting  apparatus.  Weber's 
test  is  especially  valuable  in  differentiating  between  affections  of  the  sound- 
conducting  and  the  sound-perceiving  mechanisms.  If  deafness  in  one  ear  exists, 
and  the  tone  of  the  fork  is  heard  by  bony  conduction  more  distinctly  in  that 
ear,  a  defect  in  the  conducting  apparatus  of  that  ear  is  surely  present.  When 
partial  deafness  is  present  in  both  ears,  and  the  fork  is  heard  more  distinctly 
in  the  worse  ear,  the  same  conclusion  can  be  drawn.  In  case  one  ear  only 
is  deaf,  and  Weber's  test  is  lateralized  in  the  sound  ear,  a  conclusion  of  dis- 
ease of  the  sound-perceiving  apparatus  (acoustic  nerve)  can  only  be  drawn 
in  the  presence  of  a  positive  Rinne's  test,  and  some  other  conditions  which 
will  probably  require  the  expert  judgment  of  an  ear  specialist  to  interpret 
correctly. 

Rinne's  Test. — If  a  vibrating  tuning  fork,  best  of  large  size  and  low  pitch, 
is  placed  upon  the  mastoid  process  of  an  individual  with  normal  ears,  the  tone 
will  be  heard  for  a  certain  time,  and  gradually  cease  to  be  perceived.  If,  now, 
without  striking  the  fork  again,  it  be  removed  from  the  bone  and  its  tines  be 
held  close  to  the  external  auditory  meatus,  the  sound  will  again  be  perceived 
for  a  certain  time.  The  result  of  the  experiment  is  positive.  "  Positive  Rinne  " 
— i.  e.,  the  sound  is  heard  longer  by  air  conduction  than  by  bone  conduction. 
In  many  cases  of  disease  of  the  conducting  apparatus  the  test  will  be  negative. 
The  tone  will  be  heard  longer  and  better  by  bone  conduction  than  by  air  con- 
duction. The  fork  removed  from  the  bone  and  placed  near  the  ear  is  not  heard, 
"  Negative  Rinne."  The  diagnostic  value  of  Rinne's  test  has  certain  limita- 
tions. If  the  test  is  negative,  the  more  the  efficiency  of  bone  conduction  exceeds 
that  of  air  conduction,  the  greater  the  likelihood  of  disease  of  the  conducting 


510  INJURIES    AND   DISEASES    OF   THE   EAE 

apparatus.  A  positive  result,  on  the  other  hand,  makes  a  defect  of  the  acoustic 
nerve  probable  only  when  sound  perception  by  bone  conduction  is  very  greatly 
decreased,  and  other  signs  and  symptoms  point  to  disease  of  the  nerve  (Pollak). 

It  is  found  that  disturbances  of  the  conducting  apparatus  are  more  apt  to 
cause  deafness  for  low  notes.  Such  deafness  is  common  in  acute  and  chronic 
inflammation  of  the  middle  ear.  Affections  of  the  acoustic  nerve  are  apt  to 
cause  deafness  for  high  notes.  These  facts  are  utilized  in  diagnosis-  by  using 
a  series  of  tuning  forks  ranging  from  a  low  to  a  high  pitch,  and  Galton's 
whistle. 

Catheterization  of  the  Eustachian  Tube. — Catheterization  of  the  Eustachian 
tube  is  used  to  determine  the  permeability  of  the  tube— i.  e.,  whether  a  free 
communication  exists  between  the  pharynx  and  the  middle  ear ;  to  determine 
the  mobility  of  the  tympanic  membrane ;  to  detect  the  presence  of  exudates  of 
various  kinds  in  the  middle  ear;  and,  sometimes,  to  detect  the  presence  of 
perforations  of  the  tympanic  membrane.  The  therapeutic  uses  of  the  Eu- 
stachian catheter  do  not  concern  us  here.  Eustachian  catheters  are  made  in 
several  sizes,  of  hard  rubber  or  metal.  The  catheter  is  inserted  into  the  orifice 
of  the  Eustachian  tube  through  the  nose  by  one  of  two  methods. 

Eirst  Method. — The  patient's  head  should  be  supported  by  the  back  of  a 
chair  or  the  wall.  The  catheter  is  held  lightly  between  the  finger  and  thumb, 
near  the  handle,  with  the  beak  directed  downward.  The  surgeon  sits  or  stands 
in  front  of  the  patient,  places  the  fingers  of  his  empty  hand  upon  the  patient's 
forehead,  and  with  his  thumb  elevates  the  tip  of  the  nose,  so  as  to  bring  the 
opening  of  the  nostril  above  the  level  of  the  floor  of  the  nasal  cavity.  The 
catheter  is  then  very  gently  pushed,  beak  downward,  backward  along  the  floor 
of  the  nose,  until  it  touches  the  posterior  pharyngeal  wall.  It  is  then  with- 
drawn until  the  beak  comes  in  contact  with  the  posterior  surface  of  the  soft 
palate.  By  means  of  the  handle,  the  beak  is  then  rotated  upward  and  outward, 
until  the  ring  on  the  handle  points  to  the  outer  canthus  of  the  eye  on  that  side. 
The  point  should  then  be  at  the  orifice  of  the  Eustachian  tube,  in  which  it 
should  readily  engage.  Its  introduction  is  sometimes  aided  by  asking  the 
patient  to  swallow.  If  the  catheter  is  in  the  tube  it  is  firmly  held,  and  can 
be  neither  rotated  nor  pushed  forward.  Swallowing  movements  should  cause 
the  catheter  to  move,  but  speaking  and  swallowing  should  not  be  interfered 
with  by  the  presence  of  the  catheter.  Moreover,  the  injection  of  air  through 
the  catheter,  by  means  of  Politzer's  bag,  should  be  distinctly  felt  by  the  patient 
to  distend  the  middle  ear,  and  by  the  use  of  the  auscultation  tube  the  surgeon 
should  hear  it  also. 

Second  Method. — The  catheter  is  introduced  through  the  nose,  as 
before,  until  the  beak  comes  in  contact  with  the  posterior  wall  of  the  pharynx. 
The  beak  of  the  catheter  is  then  rotated  toward  the  opposite  side  of  the  pharynx 
until  it  is  horizontal.  The  catheter  is  then  withdrawn  until  a  sense  of  resist- 
ance is  felt  as  the  curved  beak  comes  in  contact  with  the  septum  of  the  nose; 
the  catheter  is  then  rolaled  so  that  its  beak  passes  through  a  little  more  than 


EXAMINATION    OF   THE    EAR 


511 


a  semicircle,  at  first  downward,  and  then  upward,  toward  the  orifice  of  the 
Eustachian  tube,  until  the  ring  on  the  handle  is  directed  toward  the  outer 
angle  of  the  eye.  The  beak  is  then  in  position  to  eater  the  Eustachian  tube. 
In  the  presence  of  marked  deformity  or  narrowing  of  the  nasal  fossa,  or  of 
tumors,  adenoid  growths,  or  other,  in  the  pharynx  in  children,  in  acute  inflam- 
mations of  the  Eustachian  tube,  in  the  nervous  and  hysterical,  and,  in  some 
instances,  where  the  operation  is  followed  by  coughing,  retching,  etc.,  the  intro- 
duction of  the  catheter  is   difficult  or  impracticable. 

Politzer's  Method  of  Testing-  the  Eustachian  Tube. — Another  method  of  de- 
termining the  permeability  of  the  Eustachian  tube  and  of  inflating  the  middle 
ear  is  by  means  of  Politzer's  bag.  The 
instrument  consists  of  a  soft-rubber  bag 
about  the  size  of  a  man's  fist,  with  a  hole 
on  one  side,  which  can  be  closed  by  the 
finger.  A  soft-rubber  tube  is  attached  to 
the  bag  and  has  a  hard-rubber  nozzle  at  the 
end  of  it  for  insertion  into  the  nose.  In 
conjunction  with  this  apparatus  the  auscul- 
tation tube  is  useful.  It  consists  of  a  piece 
of  soft-rubber  tubing  of  suitable  length,  into 
either  end  of  which  is  inserted  a  hard-rubber 
nozzle  of  such  size  that  it  fits  tightly  into 
the  external  auditory  meatus.  When  the 
middle  ear  is  to  be  inflated  by  the  Eusta- 
chian catheter  or  the  Politzer's  bag,  the 
surgeon  introduces  one  of  the  nozzles  of 
the  auscultation  tube  into  his  own  ear  and 
the  other  into  the  ear  of  the  patient.  The  surgeon  can  then  plainly  hear  the 
normal  and  pathological  sounds  produced  when  air  enters  the  middle  ear  of 
the  patient. 

Politzer's  bag  is  used  according  to  the  directions  of  its  inventor  in  the  fol- 
lowing way: 

The  patient,  seated  in  a  chair,  takes  a  little  water  in  his  mouth,  which  he  is 
required  to  swallow  when  told.  The  surgeon,  standing  on  the  patient's  right,  intro- 
duces the  nozzle  of  the  Politzer  bag  (see  Fig.  181)  1  cm.  into  the  corresponding 
nasal  orifice,  and  then  compresses  with  the  left  thumb  and  forefinger  the  ala?  of  the 
nose  closely  around  the  instrument.  The  patient  is  next  told  to  perform  an  act  of 
swallowing,  and  at  the  same  moment  the  surgeon  expels  the  air  from  the  inflating 
bag  with  his  right  hand.  By  the  condensation  of  air  produced  in  the  nasopharynx 
in  this  manner,  the  closure  effected  by  the  soft  palate  is  forced  open,  and  its  vibra- 
tions give  rise  to  a  dull,  gurgling  sound,  which  frequently,  if  not  always,  may  be 
taken  as  an  indication  that  the  air  has  entered  into  the  middle  ear.  The  majority 
of  the  patients  experience  at  the  same  time  the  subjective  sensation  of  a  current  of 
air  entering  both  tympanic  cavities. 


512  IXJUEIES   AND   DISEASES    OE   THE   EAR 

Valsalva's  Method  of  Inflating1  the  Middle  Ear. — The  patient  stops  his  nos- 
trils by  pinching  his  nose  between  his  finger  and  thumb,  closes  his  mouth,  makes 
an  expiratory  effort,  and  *at  the  same  instant  swallows.  The  act  of  swallowing 
tends  to  relax,  or  to  open  the  Eustachian  tube,  and  air  under  pressure  is,  under 
normal  conditions,  forced  into  both  middle  ears.  If  the  effort  is  successful, 
the  patient  hears  a  fairly  sharp  snap  in  both  ears,  and  feels  a  sense  of  disten- 
tion. The  sounds  heard  by  the  surgeon  under  pathological  conditions  with  the 
auscultation  tube  as  air  enters  the  middle  ear  are  of  a  varied  character,  and 
their  pathological  significance  can  hardly  be  learned  except  by  considerable 
practice.  Normally,  the  air  may  be  heard  to  enter  the  middle  ear  with  a 
sharp,  clean-cut  popping,  or  friction  sound.  If  the  ear  is  filled,  or  partly 
filled,  with  an  exudate,  the  character  of  the  sounds  heard  will  vary  with  the 
physical  quality  of  the  exudate.  If  it  is  thin  and  watery,  the  sound  will 
be  a  fine  bubbling;  if  the  exudate  is  thick  and  viscid,  a  coarse  bubbling  sound 
will  be  heard ;  if  the  exudate  is  very  thick  or  dry,  the  sound  will  resemble  the 
friction  sounds  of  dry  pleurisy.  If  the  eardrum  is  perforated,  a  characteristic 
squeaking  or  whistling  sound  will  be  produced.  Many  of  the  diseases  of  the 
ear  require  such  special  skill  for  their  recognition  that  their  diagnosis  is  not 
likely  to  interest  the  general  surgeon,  and  only  those  diseases  of  the  ear  which 
properly  belong  to  general  surgery  will  be  here  considered. 

THE    MIDDLE    EAR 

Acute  Suppurative  Inflammation  of  the  Middle  Ear. — Acute  suppurative  in- 
flammation of  the  middle  ear  occurs  as  the  result  of  infection  of  the  mucous 
membrane  of  the  middle  ear  with  one  or  other  of  any  of  the  bacteria  capable 
of  causing  suppuration.  The  disease  is  especially  frequent  as  a  complication 
of  the  acute  exanthemata  in  children,  and  may  follow  infected  traumatisms 
of  the  tympanum,  erysipelas,  diphtheria,  syphilis,  influenza,  pneumonia, 
typhoid,  or  typhus  fevers.  It  also  may  follow  acute  or  chronic  naso-pharyn- 
gitis,  tonsillitis,  etc.  The  middle  ear  becomes  acutely  inflamed  and  filled  with 
an  exudate  of  a  muco-purulent  or  purulent  character. 

The  diagnosis  of  the  disease  is  made  from  the  symptoms  and  signs.  The 
symptoms  are  a  feeling  of  fullness  and  distention  in  the  ear,  which  follows 
immediately  upon  the  inflammatory  closure  of  the  Eustachian  tube.  There 
are  ringing  or  buzzing  noises  in  the  ear.  There  may  be  giddiness  or  vertigo. 
There  is  deafness  more  or  less  complete.  Pain,  at  first  dull,  then  sharp  and 
:-evere  and  throbbing.  In  children  there  is  often  fever.  There  may  be  facial 
paralysis.  There  may  be  tenderness  over  the  mastoid  process.  The  deafness 
may  be  of  any  grade.  The  tuning  fork  shows  that  aerial  conduction  is  dimin- 
ished, bone  conduction  is  present,  and  often  increased  in  the  affected  ear — 
i.  e.,  Weber's  test  is  lateralized  in  the  affected  ear.  If  the  labyrinth  becomes 
infected,  bone  conduction  is  lost.  The  disease  may  involve  the  mastoid  antrum, 
the  petrous  portion  of  the  temporal  bone,  and  cause  pachymeningitis,  menin- 


THE   MIDDLE   EAR  513 

git  is,  sinus  phlebitis,  pyemia,  with   their  characteristic  signs  and  symptoms, 

as  described  in  another  place.  In  had  cases  a  fatal  result  may  occur  in  this 
manner  in  two  or  three  clays  from  the  commencement  of  the  attack.  In  the 
ordinary  cases  examination  of  the  tympanic  membrane  shows  hyperemia  of 
the  eardrum,  at  first  localized  behind  the  manubrium,  soon  becoming  general; 
followed  by  dullness  and  opacity  of  the  entire  membrane.  As  the  amount  of 
exudate  increases  the  membrane  bulges  outward,  usually  more  prominently  at 
some  particular  point,  and,  if  unrelieved  by  operation,  perforation  of  the  ear- 
drum usually  takes  place  at  the  point  of  greatest  bulging,  in  two,  three,  five 
days,  or  longer.  After  the  rupture  of  the  eardrum  the  pain  usually  subsides; 
there  is  a  discharge  of  pus  from  the  external  ear,  and,  generally,  a  relief  of  all 
the  symptoms. 

In  little  children  the  symptoms  first  noticed  are  chiefly  those  of  pain  and 
of  tenderness  in  the  region  of  the  ear.  They  are  apt  to  cry  out  loudly  when 
the  ear  is  disturbed  or  washed.  They  also  exhibit  very  marked  constitutional 
symptoms  of  infection.  They  may  have  high  fever,  intense  headache,  stupor, 
and  even  unconsciousness  and  general  convulsions ;  all  of  which  are  quickly 
relieved  by  puncture  of  the  tympanic  membrane,  or  a  rupture  of  the  ear- 
drum of  such  size  that  the  pus  has  a  free  outlet.  If  the  perforation  is  small, 
the  symptoms  may  diminish  in  severity,  or  get  better,  and  again  grow  worse 
if  the  outlet  is  closed,  or  drainage  imperfect.  After  the  rupture  or  incision 
of  the  eardrum  the  discharge  from  the  ear  usually  becomes  thicker  and  more 
viscid,  and  after  a  few  days  changes  to  a  muco-purulent  character,  and  finally 
to  mucus,  after  which  it  ceases.  The  healing  of  the  perforation  in  the  drum 
membrane  takes  place  slowly ;  in  favorable  cases  in  about  three  weeks.  In 
some  cases  the  acute  inflammation  leaves  behind  permanent  changes  in  the  ear- 
drum, and  the  structures  of  the  middle  ear  of  a  hypertrophic  or  sclerotic  char- 
acter, and  permanently  impaired  hearing.  If  the  pain,  fever,  and  other  con- 
stitutional symptoms  continue,  or  grow  worse,  after  a  free  discharge  of  pus 
has  occurred  through  the  tympanic  membrane,  it  indicates  probable  involve- 
ment of  the  bone,  or  mastoiditis,  or  infection  of  the  interior  of  the  skull.  These 
serious  complications  are,  however,  relatively  infrequent  as  the  result  of  acute 
inflammation  of  the  middle  ear ;  they  are  much  more  common  as  a  complication 
of  the  chronic  form. 

Chronic  Inflammation  of  the  Middle  Ear. — Chronic  inflammation  of  the  mid- 
dle ear  follows  the  acute  form  of  the  disease  in  a  considerable  proportion  of 
cases.  Depressed  states  of  health,  imperfect  drainage,  delayed  or  imperfect 
operation,  involvement  of  bone,  the  formation  of  granulations  in  the  middle 
ear,  favor,  or  cause,  the  continuance  of  the  inflammation.  Middle-ear  disease 
complicating  scarlet  fever  seems  peculiarly  liable  to  assume  a  chronic  form. 
The  disease  is  characterized  by  a  chronic  purulent  discharge  from  the  ear, 
and  by  the  presence  of  a  perforation  in  the  eardrum  visible  on  inspection.  The 
perforation  may  be  of  any  size  and  shape,  either  quite  small,  or  practically 
the  entire  eardrum  may  be  destroyed.  The  symptoms  are:  Deafness,  which 
34 


514  INJURIES   AND   DISEASES    OE   THE   EAR 

may  be  moderate,  or  very  marked ;  there  is  usually  little  or  no  pain  until  the 
occurrence  of  some  acute  inflammatory  complication ;  subjective  sensations  of 
noise  in  the  head  are  the  exception  rather  than  the  rule.  In  case  the  outlet  for 
the  pus  becomes  closed,  or  from  an  acute  inflammatory  exacerbation,  symptoms 
will  be  produced  resembling  those  of  acute  inflammation  of  the  middle  ear. 

The  importance  of  chronic  inflammation  of  the  middle  ear  lies  in  the  fre- 
quent occurrence,  even  after  the  disease  has  existed  for  many  years,  of  inflam- 
matory complications  involving  the  cellular  cavities  connected  with  the  middle 
ear,  especially  the  mastoid  antrum  and  the  mastoid  cells ;  further,  the  danger 
of  purulent  infection  of  the  bony  walls  of  the  middle  ear  followed  by  peri- 
ostitis, ostitis,  and  necrosis ;  the  likelihood  of  caries  and  necrosis  of  the  ossicles 
of  the  ear ;  the  spread  of  the  disease  to  the  labyrinth ;  suppurative  inflamma- 
tion of  the  petrous  portion  of  the  temporal  bone,  with  involvement  of  the 
venous  sinuses  of  the  cranium ;  and,  finally,  disease  of  the  brain  and  its  mem- 
branes. 

Diagnosis  of  Chronic  Middle-ear  Disease. — The  diagnosis  of  chronic  middle- 
ear  disease  is  not  usually  difficult.  If  the  discharge  is  profuse  there  will  often 
be  fissures,  eczema,  or  ulcerations  in  the  neighborhood  of  the  external  auditory 
meatus.  After  washing  out  the  discharge  from  the  ear,  granulations  will 
sometimes  be  seen  in  the  deeper  part  of  the  canal.  The  speculum  is  used  to 
examine  the  eardrum.  The  perforation  is  usually  single ;  varies  in  size  from 
that  of  a  needle  puncture  to  loss  of  the  entire  membrane.  It  is  most  commonly 
situated  in  the  anterior  lower  quadrant,  less  often  in  the  posterior  upper 
quadrant ;  infrequently  it  will  be  found  in  the  anterior  upper  quadrant  or  in 
the  membrane  of  Shrapnell.  The  shape  of  the  perforation  is  round,  oval,  or, 
when  it  embraces  the  handle  of  the  malleus,  kidney-shaped.  It  may  be  angular 
and  irregular.  The  edges  are  smooth,  thickened,  or  covered  with  granulations. 
The  membrane  may  be  retracted  and  adherent  to  the  bony  wall  of  the  middle 
ear.  If  the  perforation  is  large  the  mucous  membrane  of  the  middle  ear  may 
be  seen,  smooth,  white  or  red,  or  velvety,  or  covered  with  granulations  and 
rough.  The  entire  middle  ear  may  be  filled  with  granulations  or  with  chol- 
esteatomatous  masses.  There  may  be  small  granulating  areas  overlying  exposed 
or  carious  areas  of  bone,  recognizable  as  such  by  the  characteristic  grating 
sensation  transmitted  through  a  probe.  It  may  be  possible  to  recognize  the 
ossicles  covered  with  discharge,  or  carious.  The  perforation  or  the  entire  cavity 
of  the  middle  ear  may  be  filled  with  white  or  yellow  crumbly  masses  of  des- 
quamated epithelial  cells,  mixed  with  cholesterin  and  fat  crystals  (desquama- 
tive inflammation  of  the  middle  ear) — cholesteatomatous  masses.  The  dis- 
charge often  has  a  pungent,  rancid,  or  putrid  odor. 

Perforations  of  the  membrane  of  Shrapnell  are  often  hard  to  discover  on 
account  of  granulations  or  epithelial  plugs.  The  passage  of  the  Eustachian 
catheter  and  inflation  of  the  middle  ear  usually  permits  the  surgeon  to  hear 
the  characteristic  sound.  The  perforation  may  sometimes  be  further  demon- 
strated by  putting  some  light  powder — such  as  lycopodium  or  boric  acid — in 


THE   MIDDLE   EAR  515 

the  external  auditory  canal,  and  blowing  air  into  the  middle  car  through  the 
catheter.  The  powder  may  thus  be  forced  out  of  the  external  ear  as  a  little 
cloud.  The  varied  appearances  of  the  interior  of  the  middle  ear  require  con- 
siderable skill  and  practice  in  the  use  of  the  otoscope  for  their  recognition  and 
interpretation;  they  can  only  be  briefly  mentioned  here. 

Chronic  inflammation  of  the  middle  ear  may  get  well  either  with  or  without 
treatment.  The  tendency  of  the  disease  is,  however,  to  continue  indefinitely, 
sometimes  getting  better,  sometimes  worse,  the  symptoms  varying  with  general 
and  local  conditions  of  health  and  environment.  Sooner  or  later,  as  the  result 
of  imperfect  drainage,  a  catarrhal  attack,  an  influenza,  or  from  the  slow  or 
sudden  involvement  of  some  new  area  of  bone  or  mucous  membrane  by  an 
extension  of  the  infection  through  continuity  of  structure,  one  or  other  of  the 
dangerous  complications  of  middle-ear  disease  arises  and  puts  the  life  of  the 
individual  in  peril.  The  diagnosis  of  these  complications  will  here  be  discussed 
in  so  far,  merely,  as  they  are  likely  to  present  themselves  to  the  general  sur- 
geon. For  a  fuller  discussion  of  the  topic  the  reader  is  referred  to  special 
works.  Invasion  of  the  labyrinth  is  characterized  by  continuous  pain,  felt 
deeply  in  the  ear  and  usually  of  a  dull  character,  and  by  total  loss  of  bone 
conduction  of  the  sound  of  the  tuning  fork  placed  over  the  mastoid  process. 

Mastoiditis. — The  most  frequent  complication  of  middle-ear  disease  is  in- 
flammation of  the  mastoid  process.  The  mucous  membrane  of  the  antrum 
and  the  air  cells  of  the  mastoid  may  be  the  seat  of  a  catarrhal  or  purulent 
inflammation,  or  of  a  desquamative  inflammation,  with  the  formation  of  chol- 
esteatomatous  masses.  The  bone  may  be  the  seat  of  osteomyelitis  or  periostitis, 
followed  by  caries  or  necrosis.  The  signs  and  symptoms  of  mastoiditis  vary  a 
good  deal,  according  to  the  more  acute  or  chronic  character  of  the  process, 
according  to  the  structures  affected — whether  mucous  membrane,  bone,  perios- 
teum— and  according  to  the  age  of  the  patient. 

.  Tenderness  on  pressure  over  the  mastoid  process  is  one  of  the  most  con- 
stant symptoms.  Although  such  tenderness  is  quite  common  in  acute  inflam- 
mation of  the  middle  ear,  its  continuance  for  days  or  weeks  after  the  middle 
ear  has  been  drained  and  the  acute  symptoms  have  subsided  is  strongly  sug- 
gestive of  mastoid  disease.  The  persistence  of  free  purulent  discharge  from 
the  middle  ear — after  adequate  drainage  and  careful  local  treatment  in  the 
absence  of  any  evident  lesion  of  the  structures  of  the  middle  ear  itself  sufficient 
to  account  for  persistent  suppuration — renders  involvement  of  the  mastoid 
very  probable.  An  irregular  febrile  movement,  coming  without  apparent  change 
in  the  condition  of  the  middle  ear,  is  of  similar  significance.  Tenderness  may 
be  distinctly  localized  over  some  small  area,  and  points  to  a  suppuration  lim- 
ited to  or  more  intense  in  that  area.  If  such  a  tender  area  rapidly  increases 
in  size,  it  is  strong  evidence  of  a  spreading  process  in  the  bone.  Localized  or 
diffuse  tenderness  and  swelling  over  the  mastoid  point  to  periostitis.  The  swell- 
ing is  often  first  noticed  along  the  posterior  surface  of  the  mastoid  or  at  the 
root  of  the  mastoid ;  this  latter  is  the  commonest  site  for  perforation  of  the 


516  INJURIES   AND   DISEASES    OF   THE   EAE 

bone  arid  the  formation  of  an  abscess.  Some  of  the  different  points  between 
mastoiditis  and  phlegmonous  inflammation  or  abscess  in  the  soft  parts  of  this 
region  have  already  been  discussed  in  speaking  of  the  diagnosis  of  these  latter 
conditions. 

The  pain  of  mastoiditis  varies  greatly  in  intensity  according  as  the  process 
is  more  acute  or  chronic.  It  is  very  generally  present,  and  in  the  more  acute 
forms  it  may  be  severe,  and  of  a  boring  or  tearing  character.  It  is  referred  to 
the  mastoid  itself,  or  to  the  depths  of  the  ear,  or  to  the  entire  region  of  the  tem- 
poral bone.  In  chronic  cases  the  pain  may  be  absent.  Periostitis  causes  the 
most  marked  symptoms  of  pain  and  tenderness.  The  pain  may  be  continuous ; 
it  often  varies  much  in  intensity  from  hour  to  hour  and  from  day  to  day.  In 
the  acute  forms  of  the  disease,  and  notably  in  children,  there  is  fever.  The 
fever  is  more  marked,  as  a  rule,  in  children  than  in  adults.  It  is  characterized 
by  notable  irregularity,  may  be  intermittent,  and  quite  commonly  shows  marked 
exacerbations  and  remissions  from  time  to  time  without  apparent  cause.  In 
chronic  cases  and  among  adults  fever  is  frequently  absent.  Leucocytosis  will 
be  present  or  absent,  according  to  the  amount  of  septic  absorption  or  the  in- 
tensity of  the  infection. 

If  the  suppurative  process  of  the  bone  has  extended  to  the  periosteum  and 
has  involved  the  neighboring  soft  parts,  an  abscess,  a  cellulitis,  a  phlegmonous 
inflammation,  or  an  involvement  of  the  contents  of  the  cranium  will  occur  and 
give  rise  to  definite  signs  and  symptoms.  Thus  an  abscess  may  be  formed  over 
the  mastoid  process  itself ;  or  perforation  forward  may  take  place  and  cause 
edema,  redness,  and  the  formation  of  an  abscess  which  will  present  in  the 
posterior  wall  of  the  external  auditory  canal ;  or  perforation  through  the  bone 
may  take  place  in  an  upward  direction,  and  cause  purulent  pachymeningitis — 
which  may  remain  localized  and  only  be  discovered  at  the  time  of  operation 
upon  the  mastoid,  when  it  will  be  found  that  the  entire  thickness  of  the  skull 
forming  the  upper  and  inner  wall  of  the  antrum  is  carious,  and  the  removal 
of  such  bone  will  expose  the  infected  dura — and  sometimes  an  extradural  ab- 
scess, or  meningitis,  or  abscess  of  the  cerebrum.  If  the  infection  involves  the 
inner  wall  of  the  mastoid  process,  it  is  likely  to  extend  to  the  lateral  sinus  and 
cause  sinus  phlebitis  or  infection  of  the  cerebellum.  (See,  also,  Pyemia,  The 
Brain  and  its  Membranes.)  If  the  perforation  extends  downward,  it  may 
cause  cellulitis  or  phlegmonous  inflammation  of  the  intermuscular  planes  of 
the  neck.  Infection  of  the  interior  of  the  skull  may  also  occur  by  extension 
along  the  blood-vessels  or  fibrous  connective-tissue  bundles  passing  from  the 
dura  into  the  middle  ear.  Also,  infection  of  the  bony  walls  of  the  labyrinth 
and  extension  to  the  dura  by  continuity  of  structure;  in  this  case  further 
extension  involves  the  cerebellum. 

Tuberculosis  of  the  Middle  Ear. — Tuberculosis  of  the  middle  ear  usually, 
but  not  always,  occurs  in  the  presence  of  advanced  tuberculosis  of  the  lungs. 
The  diagnosis  is  to  be  made  by  the  recognition  of  tubercle  bacilli  in  the  dis- 
charge from  the  ear.     There  may  be  entire  absence  of  pain.     The  commonly 


THE    MIDDLE    EAR  517 

extensive  involvement  of  the  bone  often  causes  facial  paralysis  and  destruction 
of  the  labyrinth  with  total  deafness.     In  general,  the  prognosis  is  unfavorable. 

Pachymeningitis  externa. — Pachymeningitis  externa,  alone,  usually  occurs 
by  continuity  of  structure  through  carious  bone,  and  often  remains  as  a  local- 
ized process,  sometimes  with  the  formation  of  an  abscess  between  the  dura  and 
the  bone.  There  may  be  no  symptoms  other  than  those  referable  to  the  dis- 
eased bone.  In  other  cases  there  will  be  localized  headache;  sometimes  slight 
symptoms  of  intracranial  pressure,  such  as  a  slow  pulse,  nausea,  vomiting; 
there  may  be  dullness  or  impaired  cerebration  more  or  less  marked.  In  chil- 
dren, invasion  of  the  dura  may  be  accompanied  by  a  rigor  and  a  febrile  move- 
ment.    Distinct  localizing  symptoms  are  almost  never  present. 

Leptomeningitis. — Leptomeningitis  follows  infection  of  the  internal  surface 
of  the  dura  and  pia  mater ;.  the  acute  form,  running  a  rapidly  fatal  course  in 
a  few  days,  or  a  subacute  form,  lasting  several  weeks,  may  result.  Their 
symptoms  have  been  sufficiently  described  in  Diseases  of  the  Brain  and  its 
Membranes. 

For  the  signs  and  symptoms  of  sinus  thromhosis  and  of  abscess  of  the  brain 
following  middle-ear  diseases,  see,  also,  Diseases  of  the  Brain  and  its  Mem- 
branes. 

Osteomyelitis  of  the  Mastoid.  Abscess  in  the  Soft  Parts. — In  a  certain  num- 
ber of  cases  of  middle-ear  disease  infection  of  the  mastoid  is,  as  stated,  fol- 
lowed by  purulent  osteomyelitis  and  periostitis,  and  the  formation  of  an  ab- 
scess of  the  soft  parts.  Such  abscesses  may  break  spontaneously  and  leave 
behind  a  sinus  leading  to  carious  or  necrotic  bone.  The  diagnosis  of  these 
conditions  depends  upon  a  history  of  disease  of  the  ear,  usually  the  presence 
of  a  discharge  from  the  ear  and  a  perforation  of  the  tympanum,  the  existence 
of  a  sinus  leading  to  rough  or  exposed  bone,  readily  recognized  by  the  intro- 
duction of  a  probe.  The  suppurative  disease  of  the  mastoid  is  exceedingly 
rare  except  as  a  secondary  process  to  disease  of  the  ear  or  to  traumatism. 

Primary  Tuberculosis  of  the  Mastoid  Process. — Primary  tuberculosis  of  the 
mastoid  process  may  occur  in  children,  and  lead  to  the  formation  of  abscesses, 
sinuses,  and  tuberculous  caries,  recognizable  as  tuberculosis  by  its  chronic 
course  and  the  signs  already  described  under  Tuberculosis  of  Bone. 


CHAPTER    XVIII 
INJURIES  AND   DISEASES  OF  THE  SALIVARY  GLANDS 

Injuries  of  the  Parotid,  Submaxillary,  and  Sublingual  Glands. — From  their 
protected  positions  injuries  of  the  submaxillary  and  sublingual  glands  are  in- 
frequent, and  have  no  special  diagnostic  interest.  The  parotid  gland  is  more 
often  injured  by  cuts,  stabs,  and  the  like,  and  its  injuries  are  interesting  from 
the  fact  that  division  and  laceration  of  the  duct  of  the  gland  is  sometimes  fol- 
lowed by  salivary  fistula.  Incisions  into  and  accidental  wounds  of  the  gland 
itself  usually  heal  promptly.  A  slight  discharge  of  saliva  is  sometimes  ob- 
served in  those  wounds,  which  do  not  heal  per  primam,  but  is  usually  of  no 
importance.  A  small,  cystlike  accumulation  of  saliva  may  occur  between  the 
wound  edges,  but  fistula  does  not  result. 

Injuries  of  Steno's  Duct. —  Injuries  of  Steno's  duct  are  of  more  interest. 
The  direction  of  the  duct  is  in  a  line  from  the  base  of  the  lobule  of  the  ear 
running  forward  to  the  red  border  of  the  upper  lip  or  a  little  higher,  and  deep 
wounds  of  the  cheek  which  cross  this  line  may  injure  the  duct.  The  duct  is 
of  small  size,  and  incised  wounds  involving  it  usually  cut  it  completely  in  two. 
The  diagnosis  of  a  division  of  the  duct  can  usually  be  made  readily  enough 
by  direct  inspection  of  the  wound  after  the  bleeding  has  been  stopped.  The 
ends  of  the  duct  can  often  be  seen  in  the  wound.  In  cases  of  doubt,  the  patient 
may  be  given  something  to  chew  which  will  excite  the  flow  of  saliva.  Saliva 
will  then  appear  in  the  wound.  The  diagnosis  may  be  further  confirmed  by 
passing  a  small  probe  through  the  orifice  of  the  duct  in  the  mouth  into  the 
Avound ;  in  order  to  do  this,  the  corner  of  the  mouth  is  pulled  forward,  upward, 
and  outward,  when  the  orifice  of  the  duct  can  be  seen  and  the  probe  introduced. 
The  orifice  of  the  duct  lies  normally  opposite  the  second  molar  tooth  of  the 
upper  jaw. 

Salivary  Fistula. — When,  as  the  result  of  an  injury  or  of  disease,  there  is 
an  abnormal  opening  left,  either  on  the  skin  or  the  mucous  membrane  of  the 
cheek,  through  which  saliva  flows,  the  condition  is  known  as  salivary  fistula. 
As  a  general  rule,  the  fistula3  which  open  upon  the  mucous  membrane  of  the 
mouth  are  of  no  consequence.  Those  which  open  upon  the  cutaneous  surface 
of  the  cheek  are  sometimes  annoying  and  troublesome.  If  these  fistula1  com- 
municate merely  with  the  glandular  tissue,  or  a  small  branch  of  the  duct, 
they  nearly  always  heal  spontaneously  in  the  course  of  weeks  or  months.  If 
518' 


FORMATION   OF   CALCULI   IN   THE    SALIVARY   DUCTS  519 

they  involve  Steno's  duct  itself,  they  frequently  do  not.  The  diagnosis  of  the 
presence  of  the  fistula  is  simple.  A  small  opening  exists  in  the  skin  of 
the  cheek,  through  which  saliva  flows ;  the  opening  is  usually  in  the  line  of  the 
duct,  but  may  be  removed  from  it  some  distance  in  case  injury  to  the  duct  has 
been  followed  by  an  abscess  which  has  opened,  at  a  distance  from  the  duct, 
and  has  left  a  fistulous  tract  behind.  If  it  can  be  demonstrated  that  the  periph- 
eral portion  of  the  duct  is  closed,  or  if  the  cutaneous  orifice  of  the  fistula  and 
the  mucous  membrane  of  the  mouth  are  adherent  one  to  the  other,  or  if  there 
has  been  a  considerable  loss  of  substance  in  the  duct  itself,  the  fistula  will  be 
permanent,   and  will  require  a  surgical   operation  for  its  relief. 

Foreign  Bodies  in  the  Salivary  Ducts. — Foreign  bodies  get  into  the  duct  of 
the  submaxillary  gland  more  often  than  into  Steno's  duct.  Such  foreign 
bodies  may  be  hairs  or'  bristles,  pointed  bits  of  wood,  fish  bones,  minute 
fruit  seeds,  a  small  bird  shot,  and  the  like.  If  the  foreign  body  is  small, 
it  may  produce  no  symptoms  at  all,  or,  if  larger,  it  may  set  up  irritation 
or  inflammation  of  the  duct  and  of  the  gland,  with  the  production  of  an  abscess ; 
sometimes,  of  a  salivary  fistula ;  or  the  foreign  body  may  become  the  nucleus 
of  a  salivary  calculus,  and  by  damming  back  the  saliva  in  the  duct  may  cause 
quite  serious  symptoms.  At  the  moment  of  the  introduction  of  the  foreign  body 
the  patient  may  experience  severe  pain  in  the  duct  itself  and  in  the  salivary 
gland.  If  the  body  is  large  enough  to  interfere  with  the  flow  of  the  saliva, 
it  may  cause  painful  swelling  and  inflammation  of  the  gland. 

The  diagnosis  is  sometimes  easy  and  sometimes  quite  difficult.  The  for- 
eign body  may  be  seen  protruding  from  the  orifice  of  the  duct  on  inspection ; 
or  it  may  be  felt  by  palpation  with  the  finger,  along  the  line  of  the  duct  in 
the  mouth.  Occasionally  it  may  be  possible  to  introduce  a  fine  probe  into  the 
duct  and  feel  the  foreign  body.  If  the  foreign  body  happens  to  be  metallic, 
as,  for  example,  a  bird  shot,  or  if,  as  is  sometimes  the  case,  it  has  remained 
for  some  time  in  the  duct,  and  become  coated  with  lime  salts,  it  might  be 
detected  by  means  of  the  X-rays.  In  many  instances  the  surgeon  will  not  see 
the  patient  until  the  foreign  body  has  been  present  for  some  time.  There  will 
then  usually  be  a  history  of  a  sudden  sharp  pain  in  the  salivary  gland  and 
in  the  duct,  followed  by  continuous  or  intermittent  swelling  of  the  gland  and 
pain.  Upon  inspection  and  palpation  in  the  mouth,  the  orifice  of  the  duct 
may  be  red  and  swollen;  the  duct  may  be  enlarged,  hard,  and  tender;  there  may 
be  a  purulent  discharge  from  its  orifice.  The  salivary  gland  will  usually  be 
enlarged  and  swollen. 

Formation  of  Calculi  in  the  Salivary  Ducts. — The  formation  of  calculi  in 
the  salivary  ducts  is  a  comparatively  rare  disease ;  such  calculi  occur  most  often 
in  Wharton's  duct — the  duct  of  the  submaxillary  gland.  They  may  be  single 
or  multiple.  The  symptoms  produced  by  salivary  calculi  depend  upon  the 
mechanical  stoppage  of  the  duct,  due  to  the  presence  of  the  calculus  and  to 
infection.  In  some  cases  the  calculus  may  exist  in  the  duct  for  a  long  time 
without   producing   any   symptoms.      In   other   cases   the   symptoms   are   very 


520        INJURIES   AND   DISEASES    OF    THE    SALIVAEY   GLANDS 

marked  indeed.  They  consist  of  sharp  attacks  of  pain,  coming  on  suddenly, 
excited  hy  the  act  of  eating,  or  even  by  the  sight  of  food;  the  pain  is  quite 
severe,  and  is  felt  in  the  floor  of  the  mouth  and  in  the  submaxillary  region. 
The  pain  is  followed  by  swelling  of  the  submaxillary  gland  and  of  the  duct. 
The  pain  and  swelling  continue,  sometimes  for  hours,  to  be  followed  by  the 
discharge  of  a  considerable  quantity  of  saliva  into  the  mouth  and  temporary 
relief  of  the  symptoms.  In  other  cases  the  characteristic  attacks  are  wanting. 
There  is  a  chronic  or  intermittent  discharge  of  pus  from  the  duct  of  the  gland, 
and  a  chronic  inflammation  and  enlargement  of  the  gland  itself.  The  condi- 
tion may  eventuate  in  a  phlegmonous  inflammation  of  the  salivary  gland  with 
the  production  of  an  abscess  in  the  submaxillary  region  of  the  neck  or  in  the 
floor  of  the  mouth. 

The  diagnosis  of  salivary  calculus  in  Wharton's  duct  is  sometimes  very 
easy  and  sometimes  difficult.  If  the  calculus  can  be  felt  as  a  hard  body  by 
palpation  in  the  floor  of  the  mouth,  or  by  bimanual  palpation,  it  is  not  likely 
to  be  mistaken  for  anything  else.  In  case  the  stone  lies  immediately  beneath 
the  mucous  membrane  not  far  from  the  orifice  of  the  duct,  it  may  sometimes 
be  seen  as  a  whitish  body  shimmering  through  the  thinned  mucous  membrane. 
The  stone  may  sometimes  be  detected  by  introducing  a  fine  probe  into  the  duct, 
or  if  the  probe  cannot  be  inserted,  and  a  hard  mass  is  felt  rather  deeply  placed, 
a  needle  may  be  introduced  into  the  tissues,  and  by  the  grating  sensation 
imparted  when  it  strikes  the  stone  the  diagnosis  will  be  made  clear.  The  diag- 
nosis has  also  been  made  in  several  instances  by  means  of  the  X-rays.  In  case 
marked  inflammatory  symptoms  are  present,  the  diagnosis,  in  the  absence  of 
a  characteristic  history,  is  apt  to  be  missed.  The  swollen  gland  may  be  mis- 
taken for  almost  any  sort  of  an  inflammatory  or  even  malignant  growth.  In 
one  case  Avhich  I  saw  of  salivary  calculi,  the  patient  had  already  been  operated 
upon,  and  two  calculi  removed  from  Wharton's  duct.  The  disease  had  recurred, 
and  the  patient  was  suffering  from  frequently  repeated  attacks  of  pain.  Three 
calculi  were  present,  each  about  the  size  of  a  dried  pea ;  two  of  them  were  pal- 
pable readily  enough  in  the  floor  of  the  mouth;  the  third  lay  deeply  embedded 
in  the  substance  of  the  gland.  The  patient  desired  to  have  his  submaxillary 
gland  removed.  This  I  did  with,  of  course,  a  cure  of  the  pain  from  which 
he  had  suffered. 

Inflammations  of  the  Salivary  Glands. — Inflammations  of  the  salivary  glands 
are  caused,  in  nearly  all  cases,  by  the  invasion  of  the  orifices  of  the  glandular 
ducts  in  the  mouth  by  pathogenic  microbes,  and  the  subsequent  extension  of 
bacterial  infection  along  the  ducts  of  the  glandular  tissue.  The  pyogenic  cocci, 
the  pneumococcus,  the  bacillus  typhosus  are  more  often  present  than  other 
forms.  Epidemic  parotitis,  or  mumps,  is  probably  no  exception  to  this  manner 
of  infection,  since  the  swelling  of  the  parotid  is  nearly  always  preceded  by  a 
more  or  less  marked  stomatitis.  A  dirty  mouth,  stomatitis  of  all  kinds,  whether 
due  to  bad  teeth,  or  neglect  of  the  mouth,  or  to  mercurial  or  lead  poisoning,  or 
scurvy,   are  favorable  to  infection.     Acute   infectious  diseases — scarlet  fever, 


INFLAMMATIONS    OF   THE   PAROTID    GLAND  521 

typhoid,  diphtheria,  measles,  small-pox,  typhus  fever — are  not  uncommonly 
complicated  by  inflammation  of  the  parotid.  Further,  surgical  operations, 
notably  abdominal  and  pelvic  operations,  whether  clean  or  infected ;  pyemia ; 
and  other  septic  diseases,  may  all  be  followed  by  parotitis. 

Epidemic  Parotitis  (Mumps). — An  infectious,  contagious  disease,  prob- 
ably caused  by  a  specific  microbe,  occurs  sometimes  in  epidemics,  and  is 
characterized  by  swelling  and  inflammation  of  one  or  both  parotid  glands. 
Sometimes  by  inflammation  of  the  other  salivary  glands,  and  by  more  or  less 
marked  constitutional  symptoms.  Inflammations  of  the  mammary  gland  and 
ov;u*y  occur  as  complications  in  females  and  of  the  testis  in  males.  The  in- 
flammation usually  ends  in  resolution  and  restitutio  ad  integrum ;  very  rarely 
in  suppuration.  Children  between  the  ages  of  two  to  sixteen  years  are  most 
commonly  affected,  less  often  adults.  The  period  of  incubation  is  about  two 
weeks;  there  are  usually  prodromal  symptoms  lasting  from  two  to  ten  days. 
They,  are  stomatitis,  disturbances  of  digestion,  sometimes  diarrhea,  loss  of  appe- 
tite and  nausea,  malaise,  and  slight  fever.  Suddenly  one  or  both  parotid  glands 
become  painful  and  rapidly  swollen  and  tender ;  there  is  a  decided  rise  of  tem- 
perature. The  swelling  of  the  parotid  causes  a  marked  prominence  and  char- 
acteristic deformity.  There  is  pain  on  swallowing  and  speaking,  the  motion 
of  the  jaw  is  limited.  In  uncomplicated  cases  the  fever  lasts  about  a  week,  and 
subsides  by  crisis.  The  swelling  of  the  parotid  slowly  subsides  and  is  gone  at 
the  end  of  ten  days ;  sometimes  not  for  two  or  three  weeks.  Successive  involve- 
ment of  other  glands  causes  a  prolongation  of  the  constitutional  symptoms. 
Involvement  of  the  ovary  is  accompanied  by  pain  and  tenderness,  sometimes  by 
vulvo-vaginitis  and  a  muco-purulent  discharge.  Involvement  of  the  testis  is 
attended  by  marked  swelling  of  the  testis  itself,  not  of  the  epididymis  or  vas. 
In  one  third  of  the  cases  of  testicular  involvement,  atrophy  of  the  organ,  com- 
plete or  partial,  follows. 

Inflammations  of  the  Parotid  Gland. — The  acute  inflammations  of  the  parotid 
gland,  complicating  sepsis,  acute  infectious  fevers,  and  surgical  operations,  are 
of  more  interest  because  they  not  infrequently  end  in  suppuration.  They 
appear  during  the  later  Aveeks  of  typhoid,  scarlet  fever,  etc. ;  in  the  presence 
of  an  infected  fracture ;  after  an  operation  for  pus  tubes,  an  appendicitis,  etc. ; 
or  in  the  presence  of  an  ordinary  stomatitis,  or  of  a  mercurial  or  lead  stomatitis, 
or  of  scurvy. 

The  inflammation  of  the  parotid  usually  comes  on  quite  suddenly,  and,  if 
the  infection  is  of  a  severe  type,  is  often  accompanied  by  a  chill,  a  marked 
rise  of  temperature,  prostration,  a  rapid  pulse,  leucocytosis,  and  other  septic 
symptoms;  or  if  the  infection  is  of  a  mild  type,  pronounced  general  symp- 
toms may  be  absent.  The  swelling  of  the  gland  is  first  noticeable  at  the  angle 
of  the  jaw  in  front  of  the  ear.  The  lobule  of  the  ear  is  raised  and  prominent; 
the  swelling  gradually  involves  the  entire  parotid  region.  If  the  process  is  to 
end  in  resolution,  the  swelling,  pain,  etc.,  and  the  constitutional  symptoms, 
gradually   subside   after  a   few  days.      If,    as   is  quite   common,    suppuration 


522        INJURIES    AND    DISEASES    OF    THE    SALIVARY    GLANDS 

occurs,  the  local  and  general  symptoms  become  more  marked.  The  overlying 
skin  becomes  swollen,  edematous,  and  red.  Fluctuation  is  hard  to  make  out 
because  much  of  the  gland  is  covered  by  dense  fascial  structures.  The  abscess, 
if  not  incised,  may  break  into  the  external  auditory  canal,  or  upon  the  cheek, 
into  the  pharynx,  or  burrow  down  the  intermuscular  planes  of  the  neck.  If 
the  general  and  local  symptoms  continue  to  increase  after  four  or  five  days, 
the  surgeon  is  justified  in  searching  for  pus,  always  bearing  in  mind  the  rela- 
tions of  the  facial  nerve  to  the  gland.  Death  may  occur  from  septic  poisoning, 
from  venous  thrombosis  and  pyemia,  or  meningitis,  or  from  the  spread  of  the 
infection  downward  into  the  mediastinum. 

Acute  Suppurative  Inflammation  of  the  Submaxillary  Gland. — Acute  suppu- 
rative inflammation  of  the  submaxillary  gland  may  arise  from  any  of  the 
causes  already  described  as  causing  inflammation  of  the  parotid,  but  its  infec- 
tion is  less  common,  and,  generally  speaking,  when  it  does  occur,  it  is  less 
dangerous  than  is  the  case  with  the  parotid.  Suppuration  in  the  submaxillary 
triangle  is,  however,  common  as  the  result  of  purulent  infection  of  the  loose 
connective  tissue  of  that  region ;  following  stomatitis ;  infection  through  carious 
teeth ;  periostitis  and  osteomyelitis  of  the  lower  jaw ;  suppuration  of  the  sub- 
maxillary lymph  nodes;  and,  less  commonly,  from  infection  of  the  submaxillary 
gland  itself.  The  diagnosis  does  not  materially  differ  from  that  of  the  con- 
dition about  to  be  described  which  has  received  a  special  name — that  of  the 
man  who  first  described  it — Ludwig,  of  Wurttemberg. 

Angina  Ludovici. — Angina  Ludovici  is  a  more  or  less  violent,  purulent, 
sometimes  gangrenous,  inflammation  of  tissues  occupying  the  submaxillary 
triangle  of  the  neck.  Characterized  by  severe  septic  symptoms ;  the  formation 
of  a  hard,  tense,  brawny  swelling  in  the  submaxillary  region;  great  pain;  dif- 
ficulty in  speaking  and  swallowing;  sometimes  by  cyanosis  and  dyspnea  from 
pressure  on  the  larynx  or  from  swelling  and  edema  of  the  throat.  The  local 
signs  and  symptoms  of  an  acute  abscess  or  of  a  phlegmonous  inflammation  are 
absolutely  typical.  If  unrelieved  by  very  early  incision,  the  whole  side  of 
the  neck  becomes  a  deep  mahogany  red,  as  hard  as  a  board ;  the  constitutional 
symptoms  threatening,  and  the  local  symptoms  of  interference  with  respiration 
alarming.  The  necrotic  and  suppurative  process  tends  to  burrow  down  the 
neck  and  into  the  mediastinum.  In  the  necrotic  forms  the  streptococcus  is 
usually  present ;  in  the  localized  abscesses,  staphylococci.  It  is  to  be  under- 
stood that  in  many  cases  the  infection  is  less  intense,  and  the  local  and  general 
symptoms  less  stormy  and  severe,  than  those  just  outlined.  In  any  case  the 
diagnosis  of  a  localized  suppurative  process  is  entirely  plain. 

Chronic  Interstitial  Inflammation  of  the  Submaxillary  Gland. — Chronic  inter- 
stitial inflammation  of  the  submaxillary  gland,  with  occasional  exacerbations  of 
acute  inflammation,  leading,  in  time,  to  the  production  of  a  considerable  tumor 
in  the  submaxillary  region — quite  hard,  often  painless,  usually  adherent  to  the 
surrounding  tissues — has  been  observed  in  a  few  cases.  The  condition  is  inter- 
esting from  ;i  diagnostic  point  of  view  because  it  is  apt  to  be  mistaken  for  a 


CYSTIC   DILATATION   OF   THE    SALIVARY   DUCTS  523 

gumma  or  a  malignant  new  growth.  On  section,  the  tabulated  glandular  char- 
acter is  preserved.  There  is  an  increased  production  of  interstitial  connective 
tissue,  abundant  round-celled  infiltration,  the  formation  here  and  there  of  small 
areas  of  granulation  tissue,  and  microscopic  abscesses  in  some  cases. 

von  Mikulicz  Disease. — A  simultaneous  symmetrical  enlargement  of  the 
salivary  glands  and  of  tear  glands,  without  inflammatory  complications,  was 
first  described  by  von  Mikulicz.  The  pathology  of  the  condition  is  obscure. 
The  diagnosis  is  made  by  inspection.  The  enlargement  of  the  salivary  and 
tear  glands  causes  visible  swellings.  The  disease  is  chronic,  and  does  not  end 
in  suppuration. 

Syphilis  and  Tuberculous  Inflammation  of  the  Salivary  Glands. — Syphilitic 
and  tuberculous  inflammation  of  the  salivary  glands  occasionally  occur.  In  the 
secondary  stage  of  syphilis  an  acute  inflammation  of  the  parotid,  not  unlike 
mumps,  has  been  observed  in  a  very  few  cases.  The  diagnosis  is  to  be  made 
by  the  presence  of  other  syphilitic  manifestations.  Gummata  also  have  been 
observed  in  the  parotid  as  slowly  growing,  nodular,  painless  tumors,  which 
may  later  undergo  softening  and  ulceration  of  a  characteristic  kind.  In 
the  absence  of  softening,  and  with  no  other  lesions  present,  a  history  of  syphilis 
being  denied,  these  gummata  would  probably  be  mistaken  for  a  new  growth. 
A  tertiary  syphilitic  sclerosis  of  the  parotid  with  induration  of  the  glandular 
tissue,  but  without  ulceration,  occasionally  occurs  as  a  late  lesion  of  syphilis. 
I  have  recently  had  such  a  case  under  my  care. 

Tuberculosis. — Primary  tuberculosis  of  the  parotid  gland  has  been  observed 
in  a  few  cases  as  a  diffuse  tubercular  infiltration  of  a  considerable  portion  of 
the  gland,  or,  less  commonly,  as  a  circumscribed  tuberculous  focus  in  the  sub- 
stance of  the  gland,  resulting  in  a  cold  abscess.  In  most  of  the  cases  the  dis- 
ease has  not  been  associated  with  other  tuberculous  lesions.  The  symptoms 
consist  of  a  chronic,  diffuse,  or  circumscribed  enlargement  of  the  gland,  usu- 
ally not  tender,  and  covered  by  normal  or,  later,  by  reddened  and  edematous 
skin.  Neuralgic  pain  is  sometimes  present.  The  disease  is  so  rare  that  a 
diagnosis  is  likely  to  he  made  only  after  operation  and  microscopic  examina- 
tion of  the  diseased  tissues.  The  circumscribed  forms  are  only  to  be  differen- 
tiated from  a  tuberculous  lymph  node  by  the  pathologist. 

Cystic  Dilatation  of  the  Salivary  Ducts. — Cystic  dilatation  of  the  salivary 
ducts,  as  the  result  of  retention  of  the  secretion  of  the  gland,  due  to  closure 
of  the  mouth  of  the  duct  from  any  cause — inflammation,  salivary  calculus,  a 
foreign  body,  or  from  no  assignable  cause — is  usually  easy  to  recognize.  The 
characteristic  signs  and  symptoms  of  the  most  common  form  of  the  condition 
have  been  described  under  Ranula.  They  occur  less  commonly  in  Steno's  and 
Wharton's  ducts,  and  are  recognizable  as  painless,  insensitive,  spindle-shaped, 
elastic  tumors  in  the  line  of  the  duct.  If  they  lie  immediately  beneath  the 
mucous  membrane  they  will  be  translucent.  Such  cysts  of  Steno's  duct  lie 
close  to  the  skin  of  the  cheek,  and,  if  such  is  the  case,  the  introduction  of  an 
aspirating  needle   into  the  cyst  through  the  skin  is  unwise,  since  a  salivary 


524        INJURIES   AND   DISEASES    OF   THE    SALIVARY   GLANDS 


fistula  might  thus  be  created.  Exploration  through  the  mucous  membrane 
can,  of  course,  do  no  harm.  The  contents  of  these  cysts  is  clear  saliva  which 
may  have  undergone  such  changes  as  not  to  respond  to  tests  for  ptyalin,  etc. 
If  the  duct  of  the  gland  is  not  entirely  closed,  it  may  be  possible  to  express 
some  of  the  contents  through  the  orifice  of  the  duct.  Cysts  of  the  Blandin-lSTuhn 
glands  present  as  translucent,  thin-walled  vesicles,  usually  of  small  size,  at, 
or  just  beneath,  the  point  of  the  tongue. 

Cysts  of  the  Salivary  Glands. — Cysts  of  the  salivary  glands  themselves  are 
rather  rare.  Unless  the  cyst  has  attained  a  considerable  size  the  diagnosis  is  not 
easy.  They  may  attain  the  size  of  a  blue  plum  or  of  a  hen's  egg ;  form  rounded, 
elastic,  fluctuating  swellings.  They  contain  clear  saliva,  and  are  most  of  them 
unilocular.  The  diagnosis  must  usually  be  made  by  puncture  with  a  hypoder- 
mic needle. 

Tumors  of  the  Salivary  Glands. — The  same  types  of  tumors  occur  in  all  the 
salivary  glands.  They  are  much  more  common  in  the  parotid  than  in  the 
submaxillary  gland.  The  connective-tissue  tumors  are  angioma,  very  rare; 
lymphangioma,  also  very  rare.  I  operated  on  one  case  of  lymphangioma  of 
the  parotid  in  a  girl  of  ten.  The  tumor  was  the  size  of  a  hen's  egg,  cov- 
ered with  normal  skin,  soft,  and  compressible,  but  a  certain  tension  was 
given  to  it  by  the  capsule  of  the  gland.  It  had  grown  slowly  and  produced 
no  symptoms  other  than  deformity.     The  tumor  was  removed,  not  easily,  and 

was  found  to  consist  of  a  tra- 
beculated  connective  tissue 
containing  large  spaces  filled 
with  clear  fluid.  Microscop- 
ic examination  showed  that 
the  tumor  was  a  lymphangi- 
oma. Lipoma. — A  few  cases 
have  been  observed,  either 
as  distinctly  encapsulated 
tumors  or  intimately  con- 
nected with  the  glandular 
substance.  Fibroma. — Hard 
or  firm  fibroma  is  rarely  ob- 
served as  a  slowly  growing 
benign  tumor  of  the  parot- 
id. Sarcoma. — The  various 
forms  of  sarcoma  occur  in 
parotid.  Fibrosarcoma  and 
spindle-celled  sarcoma  form 
firm,  rounded  tumors,  which 
remain  encapsulated  for  a  long  time,  and  remain  fairly  movable  and  are 
capable  of  enucleation  (see  Fig.  182).  The  more  malignant  types,  which 
occur  also  in  the  submaxillary  gland,  are  apt  to  grow  rapidly,  to  speedily  infil- 


Fig.  182. — Sarcoma  of  the  Parotid  Gland. 
(Collection  of  Dr.  Charles  McBurney.) 


MIXED    TUMORS    OF    THE    SALIVARY   GLANDS 


525 


trate  the  entire  glandular  structure,  to  invade  the  surrounding  structures,  to 
involve  the  skin,  the  mucous  membrane,  to  ulcerate,  bleed,  etc.  They  some- 
times grow  so  rapidly  thai  they  may 
be  mistaken  for  inflammatory  proc- 
esses. The  most  malignant  of  all  is 
melano-sarcoma. 


■  -■  —  _ 


Fig.  183. — Mixed  Tumor  of  the  Parotid  Gland. 
(Collection  of  Dr.  Charles  McBurney.) 


Fig.  1S4. — Mixed  Ttjmor  of  the  Parotid  Gland. 
(Collection  of  Dr.  Charles  McBurney.) 


Mixed  Tumors  of  the  Salivary  Glands. — The  most  frequent  and  inter- 
esting tumors  of  the  parotid  are  the  so-called  mixed  tumors.  They  are  much 
less  frequent  in  the  submaxillary  gland.  They  are  generally  tumors  of  rather 
slow  growth,  and  may  exist  for  many  years  before  they  attain  a  large  size. 
They  are  also  well  encapsulated  unless  they  undergo  malignant  degeneration. 
They  form,  when  small,  nodular,  intraglandular,  or  extraglandular  masses  of 
smooth  or  uneven  surface,  usually  somewhat  movable.  Their  consistence  is 
very  variable,  since  they  are  usually  made  up  of  a  variety  of  hard  and  soft 
tissues.  Hard  portions  alternate  with  softer  or  cystlike  areas.  These  tumors 
may  contain  many  kinds  of  tissue ;  combinations  of  enchondroma,  fibroma, 
myxoma,  adenoma,  sarcoma,  carcinoma,  endothelioma,  and  striped  muscle  fiber, 
and  bony,  calcareous,  and  cystic  areas  may  all  be  found  in  various  combina- 
tions. A  large  proportion  of  these  tumors  are  observed  between  the  ages  of 
fifteen  and  thirty  years.  A  few  are  congenital,  and  extreme  old  age  is  not 
exempt.  They  very  often  grow  slowly  for  many  years,  and  then  suddenly 
take  on  a  rapid  and  destructive  character  showing  the  qualities  of  sarcoma  or 
carcinoma,  as  the  case  may  be.  Such  malignant  changes  are  said  to  take  place 
in  about  ten  per  cent  of  all  cases.  If  seen  during  their  earlier  stages,  they 
should  be  extirpated  as  soon  as  discovered.  When  mixed  tumors  of  the  parotid 
have  attained  a  certain  size,  they  may  give  rise  to  pressure  symptoms;  pain, 


526        INJURIES    AND   DISEASES    OF   THE    SALIVARY   GLANDS 


by  pressure  on  the  branches  of  the  fifth  nerve ;  and  facial  paralysis  from  stretch- 
ing and  pressure  on  the  facial,  usually  in  its  lower  part,  thus  causing  droop- 
ing of  the  inouth,  etc.,  on  one  side. 

The  diagnosis  is  usually  not  difficult.  The  tumor  forms  a  distinct  nodular 
swelling,  and  produces  a  deformity  which  depends  upon  what  part  of  the  gland 
it  occupies  and  the  direction  in  which  it  grows.  In  the  posterior  part  of  the 
gland  the  tumor  grows  up  beneath  the  ear,  elevating  the  lobule,  or  behind  the 
jaw  toward  the  pharynx;  in  the  front  part  of  the  gland  the  tumor  produces  a 

swelling  on  the  cheek.  In  the  sub- 
maxillary region  the  tumor  pro- 
duces a  swelling  in  the  neck  be- 
neath the  jaw,  but  seldom  grows 
toward  the  floor  of  the  mouth.  If 
the  tumor  is  composed  largely  of 
cartilage,  it  will  be  very  hard  and 
of  uneven  surface.  Very  commonly 
such  cartilaginous  tumors  contain 
areas  of  myxomatous  degeneration 
which  give  a  sensation  resembling 
fluctuation. 

A  diagnosis  between  this  soft 
tissue  and  true  cyst  formation  can 
only  be  made  with  an  aspirating 
needle.  If  fibroma  predominates 
in  the  growth,  the  surface  will  be 
smooth,  and  consistence  firm.  As 
long  as  the  tumor  remains  benign 
it  will  possess  a  capsule  and  be  dis- 
tinctly movable  and  sharply  defined 
from  the  surrounding  parts.  The 
tumor  is  covered  by  normal  non- 
adherent skin,  is  not  tender,  and 
only  exceptionally  painful.  A  sud- 
denly acquired  rapidity  of  growth  is  almost  a  certain  sign  of  malignant  activity. 
If  not  soon  removed  the  capsule  will  be  lost  and  the  tumor  acquire  the  malig- 
nant characters  already  described.  While  mixed  tumors  are  of  slow  growth, 
they  produce  so  few  symptoms,  as  a  rule,  other  than  deformity  that  their 
possessors  are  apt  to  postpone  their  removal.  They  may  thus  attain  in  the 
course  of  years  a  very  large  size.     (See  illustrations.) 

Tuberculous  Lymph  Nodes  in  the  Parotid.— A  solitary  tuberculous 
gland  sometimes  occurs  in  front  of  the  ear,  and  might  be  mistaken  for  a  tumor. 
After  such  a  gland  has  existed  for  some  time  it  is  very  apt  to  become  adherent 
to  the  surrounding  tissues,  to  break  down  and  become  adherent  to  the  skin, 
showing  fluctuation. 


Fig.   185. 


-Mixed  Ttjmor  of  the  Parotid  Gland. 
(Author's  collection.) 


ADENOMA— CARCINOMA— SCIRRHUS 


527 


Adenoma. — Purely  adenomatous 

tumors  of  the  salivary  glands  have 
occasionally  been  observed.  They 
form  encapsulated  tumors,  tabulated, 
of  firm  or  soft  consistence,  usually 
of  slow  growth.  Clinically  they  are 
not  to  be  differentiated  from  mixed 
tumors. 

Carcinoma. — Carcinoma  occurs 
both  in  the  parotid  and  submaxillary 
glands,  oftener  in  the  former.  It 
is  difficult  to  say  whether  some  of 
the  epitheliomata  of  the  floor  of  the 
mouth  originate  in  the  sublingual 
gland  or  not.  The  carcinomata  of 
the  parotid  may  be  of  the  scirrhous 
variety,  or  rapidly  growing  cellular 
forms. 


'l*«fr 


Fig.  186. —  Sarcoma  of  the  Parotid 
Gland.  Round-  and  spindle-celled 
type.  Patient  remained  well  five  years 
after  operation.     (Author's  collection.) 


Scierhus. — Scirrhus  occurs 
in  old  people,  oftener  in  men 
than  women.  Its  progress  is 
relatively  slow,  and  causes  atro- 
phic changes  rather  than  the 
production  of  a  considerable 
tumor.  The  glandular  tissue 
becomes  indurated,  and  the  con- 
traction of  the  abundant  fibrous 
stroma  of  the  tumor  causes 
puckering    and    indentation    of 


Fig.  187. — Photograph  of  Patient  Shown  in  Fig.  186 
taken  soon  after  the  operation,  showing  scar 
and  Facial  Paralysis. 


the  skin  over  the  growth.  Sec- 
ondary involvement  of  the 
lymph  nodes  in  the  neck  is 
usually  late,  and  the  secondary 
tumors  rarely  attain  a  large 
size.  The  involvement  of  the 
facial  nerve  causes  paralysis  of 
the  face,  frequently  only  par- 
tial. Pain  is  rarely  marked. 
The    skin    may   be    extensively 


528        INJURIES   AND   DISEASES    OF   THE    SALIVAEY   GLANDS 

infiltrated,  and  the.  infiltration  may  extend  well  down  on  the  neck  and  limit 
the  motions  of  the  head,  causing  a  slight  degree  of  wry-neck. 

Soft  Cellular  Form  of  Cabcinoma. — The  soft  cellular  form  of  carci- 
noma presents  quite  a  different  picture.  Microscopically,  these  tumors  resem- 
ble an  acinous  gland,  with  a  poorly  developed  stroma.  They  are  rapidly  grow- 
ing forms,  soft,  soon  invade  the  skin,  ulcerate,  bleed,  often  dangerously,  undergo 
putrefactive  changes,  etc.  They  early  become  painful,  often  terribly  painful, 
cause  facial  paralysis,  often  deafness,  grow  inward  into  the  pharynx,  down- 
ward into  the  neck,  cause  difficulty  in  swallowing,  speaking,  and  breathing. 
Soon  infect  the  lymph  nodes,  forming  rapidly  growing  secondary  tumors  and 
metastases,  and  have  all  the  characters  of  the  most  malignant  growths.  The 
duration  of  life  may  be  as  short  as  six  months  after  the  discovery  of  the 
tumor.  Death  occurs  from  repeated  hemorrhages,  sepsis,  erysipelas,  exhaus- 
tion, asphyxia,  etc. 

The  diagnosis  of  carcinoma  of  the  parotid  or  submaxillary  glands  presents 
not  the  slightest  difficulty  after  the  tumors  are  far  advanced.  In  their  early 
stages,  how7ever,  when  treatment  is  still  possible,  they  may  readily  be  mistaken 
for  an  acute  or  subacute  inflammatory  process — syphilis,  tuberculosis  of  the 
soft  parts,  or  even  a  purulent  infection.  They  grow  so  fast,  so  early  become 
painful,  exhibit  redness  and  tenderness  of  the  skin,  etc.,  that  an  exploratory 
incision  and  the  removal  of  a  small  portion  of  the  tumor  for  immediate  micro- 
scopic examination  may  be  necessary,  or  at  least  desirable.  The  early  occur- 
rence of  facial  paralysis  should  lead  to  a  suspicion  of  malignant  disease.  One 
of  the  difficulties  is  that  these  rapidly  growing  cancers '.may  occur  in  quite  young 
people. 


CHAPTER   XIX 

THE  NECK 
CONGENITAL   DEFECTS   OF  THE   NECK 

Congenital  Fistulae  of  the  Neck, — Congenital  fistulse  of  the  neck  arise  from 
(1)  the  second  branchial  cleft,  (2)  from  the  thyreo-glossal  dnct. 

1.  Fistulae  Arising  from  Imperfect  Closure  of  the  Second  Branch- 
ial Cleft. — Fistula?  arising  from  imperfect  closure  of  the  second  branchial 
cleft  may  be  complete  or  incomplete.  The  incomplete  fistula?  may  have:  (a) 
An  external  opening,  but  fail  to  communicate  with  the  pharynx — incomplete 
external  fistula,  (&)  An  opening  into  the  pharynx,  but  no  opening  in  the 
skin  of  the  neck — incomplete  internal  fistula.  The  external  opening  of  these 
fistula?  lies  in  the  skin  of  the  neck,  between  the  anterior  border  of  the  sterno- 
mastoid  muscle  and  the  median  line  of  the  front  of  the  neck,  and  between  the 
greater  cornu  of  the  hyoid  bone  and  the  sterno-clavicular  joint  of  the  same 
side.  The  external  opening  is  usually  very  small,  often  so  small  as  only  to 
admit  a  filiform  guide  or  a  bristle.  The  inner  opening  lies  in  the  neighbor- 
hood of  the  tonsil,  in  the  lateral  wall  of  the  pharynx,  or  near  the  pillars  of 
the  fauces.  In  passing  from  the  skin  to  the  pharynx  the  path  of  the  fistula  is 
through  the  skin  and  superficial  fascia,  along  the  deep  fascia  covering  the  sterno- 
hyoid and  sterno-thyroid  muscles,  between  the  external  and  internal  carotid 
arteries,  to  the  neighborhood  of  the  greater  cornu  of  the  hyoid  bone,  and  thence 
to  the  pharyngeal  wall.  The  digastric  muscle  is  superficial  to  the  path  of  the 
fistula,  the  hypoglossal  and  glossopharyngeal  nerves  lie  beneath  it.  That  por- 
tion of  the  fistulous  tract  derived  from  the  hypoblast  is  lined  with  cylindrical 
epithelium.  That  portion  derived  from  the  epiblast  is  lined  with  flat  pavement 
epithelium.  This  arrangement  is  the  rule;  exceptions,  however,  may  occur. 
The  portion  derived  from  the  hypoblast  is  said-  always  to  contain  a  layer  of 
lymphoid  cells  in  its  wall.  These  fistula?  may  be  complete  or  incomplete  at 
first.  The  incomplete  fistula?  may  subsequently  become  complete  by  the  for- 
mation of  a  cystic  enlargement,  which  finally  perforates  inwardly  or  outwardly. 

The  diagnosis  of  these  fistula?,  if  present  at  birth,  is  not  difficult.  If  they 
form  secondarily,  they  may  be-  mistaken  for  sinuses  of  other  origins.  The  dis- 
charge from  the  fistula  consists  of  clear  stringy  mucus,  or  of  a  thinner,  milky, 
or  turbid  fluid  resembling  thin  pus.     The  amount  of  discharge  varies  greatly. 

It  may  be  very  slight,  scarcely  noticeable,  only  a  drop  now  and  then,  or  so  pro- 
35  529 


530 


THE   NECK 


fuse  as  to  constitute  a  serious  annoyance  and  to  cause  irritation  of  the  skin  of  the 
neck.  It  is  sometimes  possible  to  feel  the  wall  of  the  tract  as  a  fibrous  cord  in 
the  neck.  •  It  is  not  usually  possible  to  pass  any  instrument  throughout  the 
entire  length  of  the  fistulous  canal.  In  the  complete  fistulse  it  is  sometimes 
possible  to  inject  fluid  through  the  external  opening  into  the  pharynx ;  the  pas- 
sage of  the  fluid  into  the  pharynx  may  be  recognized  by  the  patient  by  its  taste, 
or  by  the  surgeon  by  its  color  (strychnin,  quinin,  milk,  or  methyl ene-blue  solu- 
tion). If  the  internal  opening  is  large,  small  portions  of  food  may  pass  from 
the  pharynx  outwardly  to  the  skin.  If  the  fistula  has  no  external  opening, 
or  if  that  opening  becomes  closed,  the  accumulation  of  food,  etc.,  in  the  tract 
may  lead  to  inflammatory  symptoms  or  even  to  the  symptoms  of  a  diverticulum 
of  the  pharynx,  regurgitation  of  the  food  into  the  pharynx,  or  difficulty  in 
swallowing.  The  character  of  the  epithelium  lining  the  tract  is  an  important 
aid  in  the  diagnosis;  cylindrical  epithelium  in  the  part  derived  from  the  phar- 
ynx (hypoblast — entoderm)  ;  pavement  epithelium  in  the  part  derived  from  the 
cutaneous  layer  (epiblast — ectoderm). 

2.  Fistula    Arising    prom    the    Thyreo-glossal    Duct. — The    thyreo- 
glossal  or  thyreo-lingual  duct   in  early  fetal  life  forms   a  canal  lined  with 

ciliated  epithelium  running  from 
the  foramen  cecum  at  the  base  of 
the  tongue,  downward  and  forward 
in  the  middle  line,  to  the  isthmus 
of  the  thyroid  gland.  This  canal, 
from  the  foramen  cecum  to  the 
hyoid  bone,  is  known  as  the  lingual 
duct.  From  the  hyoid  bone  to  the 
isthmus  of  the  thyroid  as  the  thy- 
roid duct.  "While,  normally,  the 
entire  canal  is  obliterated  in  early 
fetal  life,  in  certain  instances  it 
may  remain  patent,  throughout,  or 
in  part.  A  fistula  only  results  when 
a  communication  with  the  skin  in 
the  middle  line  of  the  neck  is  es- 
tablished. These  fistula?  are  usu- 
ally not  congenital.  The  external 
opening,  when  formed,  is  in  the 
middle  line  of  the  neck  between  the  hyoid  bone  and  the  sternum.  The  open- 
ing is  usually  minute,  and  it  is  only  possible  to  introduce  a  probe  as  far  as 
the  hyoid  bone.  The  deeper  portion  of  the  fistulous  tract  is  lined  by  ciliated 
cylindrical  epithelium ;  that  part  nearest  the  foramen  cecum  of  the  tongue 
with'  flat  epithelium.  It  is  to  be  remembered  that  suppuration  may  change 
or  destroy  this  epithelial  lining. 

Along  the  sterno-mastoid  muscle  there  occur  small  congenital  outgrowths, 


Fig.  188. — Cyst  Developed  in  a  Persistent 
Thvreoglossal  Duct.     (Author's  case.) 


CONGENITAL   DEFECTS    OF   THE   NECK  531 

sometimes  of  skin,  sometimes  containing,  also,  plaques  of  cartilage,  which  are 
believed  to  have  a  morphological  relation  with  the  branchial  arches  and  clefts. 
(See  Supernumerary  Auricles.) 

Cervical  Ribs. — Cervical  ribs  occur  not  very  rarely.  They  are  always  con- 
nected with  the  seventh  cervical  vertebra,  usually  by  a  regular  joint.  They 
are  unilateral  or  bilateral.  The  development  of  the  rib  varies  in  different  cases. 
It  may  scarcely  project  beyond  the  transverse  process  of  the  vertebra.  It  may 
extend  farther  forward  and  end  free.  It  may  unite  with  the  first  rib  proper 
by  fibrous  or  bony  union,  or  finally  with  the  sternum.  The  subclavian  artery 
passes  over  the  cervical  rib,  if  it  is  long ;  or  in  front  of  it,  if  short ;  never 
below  it.  The  brachial  plexus  lies  always  below.  The  existence  of  such  a  rib 
is  of  interest  because  it  may  cause  pressure  symptoms,  either  of  a  circulatory 
or  nervous  character. 

The  symptoms  usually  come  on  between  the  fifteenth  and  twentieth  years 
of  life.  The  circulatory  disturbances  are  caused  by  the  pressure  of  the  rib 
against  the  subclavian  artery.  In  some  cases  they  are  very  slight  or  absent; 
there  may  be  noticed  only  a  slightly  less  perfect  development  in  the  muscles 
of  the  arm,  or  the  arm  may  be  distinctly  less  well  nourished  than  its  fellow ; 
the  fingers  may  be  pale  and  cold ;  actual  gangrene  of  the  ends  of  the  fingers 
has  been  observed  in  one  case.  The  compression  of  the  artery  may  be  suffi- 
cient to  cause  thrombosis  and  obliteration  of  the  vessel,  but  the  process  is  slow, 
and  ample  time  is  permitted  for  the  establishment  of  a  collateral  circulation. 
The  symptoms  due  to  compression  of  the  brachial  plexus  of  nerves  consist  chiefly 
of  sensory  disturbances,  neuralgic  pains — either  localized  or  general — pares- 
thesia:', numbness,  coldness,  formication.  Motor  symptoms  are  absent,  except 
that  diminished  electrical  excitability  of  the  muscles  and  of  the  nerves  has 
been  observed.  The  diagnosis  is  not  usually  difficult.  Instead  of  the  normal 
flatness  or  concavity  in  the  supraclavicular  region,  a  pulsating  swelling  covered 
by  normal  skin  is  noted.  Firm  pressure  on  this  swelling  causes  obliteration 
of  the  radial  pulse,  slight  pressure  may  produce  a  thrill.  Behind  and  below 
can  be  felt  the  rib,  hard,  as  broad  as  a  finger,  attached  or  movable  in  front.  Such 
a  rib  may  be  mistaken  for  an  exostosis  of  the  first  rib.  Such  exostoses  usually 
cause  compression  of  the  vein  rather  than  the  artery  and  edema  of  the  arm.  A 
positive  diagnosis  is  easily  established  in  a  doubtful  case  by  an  X-ray  picture. 

Wry-neck  {Torticollis — Caput  obstipum). — The  term  wry-neck  is  used  to 
designate  a  variety  of  conditions  which  have  this  in  common,  that  they  are 
attended  by  shortening  or  spasm  of  some  of  the  muscles  on  one  side  of  the 
neck,  especially  of  the  sterno-mastoid  muscle,  and  are  characterized  by  a  pecul- 
iar, easily  recognizable  deformity,  such  that,  in  typical  cases,  the  chin  is 
raised  and  turned  toward  the  sound  side ;  the  ear  of  the  affected  side  is  de- 
pressed and  approached  to  the  shoulder.  (See  Fig.  ISO.)  The  occiput  is 
approximated  to  the  shoulder  of  the  affected  side.  The  deformity  varies  in 
degree  in  different  cases.  An  attempt  to  straighten  the  position  of  the  head  is 
met  by  strong  resistance  on  the  part  of  the  sterno-mastoid  and  sometimes  of 


532 


THE   NECK 


Fig.  189. — Wry-Neck  of  Congenital  Origin  in  a 
Little  Girl.  Congenital  elevation  of  the  scap- 
ula.    (Collection  of  Dr.  Charles  McBurney.) 


other  muscles.     As  a  chronic  or  permanent  condition  the  causation  and  pathol- 
ogy of  torticollis  is  somewhat  obscure.     It  is  believed,  by  some  observers — denied 

by  others — that  the  condition  is  con- 
genital in  the  sense  that  the  short- 
ening of  the  muscles  occurs  during 
intra-uterine  life.  Some  observers 
believe  that  the  condition  is  caused 
by  injury  to  the  sterno-mastoid  mus- 
cle during  labor,  sometimes  by  the 
use  of  obstetric  forceps,  or  during 
the  delivery  of  the  after-coming 
head.  This  accident  is  supposed  to 
cause  a  rupture  or  a  hematoma  in 
the  muscle,  resulting  in  the  forma- 
tion of  scar  tissue,  in  some  instances 
in  a  progressive  chronic  interstitial 
myositis  with  destruction  of  the 
muscular  fibers  and  their  replace- 
ment by  fibrous  tissue.  It  has  been 
assumed  by  some  surgeons  that  a 
hematogenous  infection  of  the  mus- 
cle injured  during  labor  takes  place  through  the  alimentary  canal,  but  this 
theory  of  causation  remains  to  be 
proven. 

The  deformity  is  generally  no- 
ticed after  the  child  is  a  few  months 
old ;  upon  examination,  the  peculiar 
position  of  the  head  is  evident ;  pal- 
pation of  the  sterno-mastoid  muscle 
upon  the  affected  side  shows  that  it 
is  hard,  inelastic,  and  stretches  as 
a  tense,  firm  band,  straight  down- 
ward from  the  mastoid  process  to 
its  insertion  in  the  clavicle  and  ster- 
num. The  hardness  and  rigidity 
of  the  muscle  is  often  most  marked 
near  its  lower  end.  If  the  child  is 
allowed  to  grow  up  with  this  condi- 
tion unrelieved,  secondary  changes 
take  place.  A  lateral  curvature  of 
the  spine  in  the  cervical  region  is 
gradually  developed  with  its  con- 
cavity toward  the  affected  side.  The  intervertebral  disks,  and  the  bodies 
of  the  cervical  vertebrEe  themselves,  are  thinner  upon  the  affected  side,  so  that 


Fig.  190. — Congenital  Wry-Neck  in  a  Boy. 
(Collection  of  Dr.  Charles  McBurney.) 


CONGENITAL   DEFECTS    OF   THE   NECK  533 

the  deformity  of  the  spine  tends  to  become  permanent.  This  scoliosis  may  con- 
tinue in  a  single  curve  into  the  dorsal  region.  Usually  a  compensatory  scoliosis 
in  the  opposite  direction  takes  place  in  the  upper  dorsal  region;  this  dorsal 
compensatory  scoliosis  is  usually  not  developed  until  the  disease  has  existed 
for  some  time.  The  two  sides  of  the  face  develop  unequally ;  upon  the  affected 
side  the  face  is  broader  and  lower  than  upon  the  other.  The  skin  upon  the 
affected  side  of  the  neck  is  often  thrown  into  folds.  All  the  structures  of  the 
neck — the  muscles,  the  blood-vessels,  the  nerves — are  shorter  upon  the  affected 
side. 

Other,  Forms  of  Wry-neck. — Tn  addition  to  this  form  of  torticollis, 
which  is  either  congenital  or  occurs  soon  after  birth,  a  number  of  other  acute 
or  chronic  conditions  give  rise  to  wry-neck.  Among  them  may  be  mentioned 
cicatricial  contraction  of  the  side  of  the  neck  due  to  burns;  cicatricial  con- 
traction of  the  skin,  or  of  the  muscles  and  fascia,  such  as  may  be  produced 
by  traumatisms  with  loss  of  substance,  and  by  phlegmonous  processes  in  the 
neck.  In  acute  inflammatory  conditions  of  the  neck — abscesses,  phlegmons,  etc. 
— the  sterno-mastoid  upon  the  affected  side  is  relaxed  for  the  relief  of  tension ; 
that  upon  the  sound  side  contracted.  As  the  result  of  tubercular  or  syphilitic 
inflammation  of  the  sterno-mastoid  muscle,  or  of  the  growth  of  tumors,  sarcoma, 
or  carcinoma  in  the  muscle,  the  sterno-mastoid  may  lose  its  elasticity,  become 
rigid  and  shortened.  Further,  as  the  result  of  dislocations  of  the  cervical  verte- 
brae, of  tuberculosis  of  the  bodies  of  the  vertebrae,  deformities,  more  or  less 
closely  resembling  typical  wry -neck,  are  not  uncommon.  (See  Dislocations 
and  Tuberculosis  of  the  Cervical  Vertebra?.) 

Further,  as  the  result  of  local  irritations,  notably  of  pediculosis  capitis, 
well-marked  spasm  of  the  sterno-mastoid  muscle  may  occur,  which  promptly 
or  slowly  disappears  when  the  irritation  is  removed.  As  the  result  of  exposure 
to  cold  and  wet,  or  from  other  causes,  the  so-called  muscular  rheumatism  may 
affect  the  sterno-mastoid  muscle.  The  attack  usually  comes  on  quite  suddenly, 
often  without  warning.  The  patient  feels  a  more  or  less  intense  pain  in  the 
side  of  the  neck,  and  the  head  involuntarily  assumes  a  wry-neck  position. 
The  muscle  is  more  or  less  tender,  and  an  attempt  to  straighten  the  head 
is  painful.  The  condition  may  last  for  hours  or  days,  and  in  very  rare  cases 
may  become  chronic.  As  a  complication  of  acute  infectious  disease — scarlet 
fever,  measles,  typhoid,  etc. — an  inflammation  of  the  sterno-mastoid  muscle 
may  occur,  and  in  some  instances  may  lead  to  permanent  replacement  of  the 
muscular  fibers  by  fibrous  tissue.  Of  all  the  muscles  of  the  neck  the  sterno- 
mastoid  is  more  often  than  any  other  the  seat  of  gummata  or  of  a  diffuse 
syphilitic  interstitial  myositis  with  replacement  of  the  muscular  fibers  by 
fibrous  tissue. 

Spasmodic  Torticollis.  Spasmodic  Wry-neck. — As  the  result  of  ob- 
scure changes  in  the  central  origins  of  the  spinal-accessory  and  the  three  upper 
Cervical  nerves,  sometimes  from  changes  in  the  nerves  themselves,  a  chronic 
condition  of  nervous  irritation  ensues,  characterized  by  tonic  or  clonic  spasms, 


534  THE   NECK 

or  both,  of  certain  muscles  of  the  neck.  The  sterno-rnastoid  is  most  often 
affected,  and  other  muscles  frequently  take  part — trapezius,  splenius,  obliquus 
capitis  inferior,  complexus — sometimes  on  both  sides  of  the  neck.  When  the 
spasm  is  tonic,  and  affects  chiefly  the  sterno-mastoid,  the  position  of  the  head 
is  that  of  ordinary  wry-neck ;  by  the  implication  of  other  muscles  the  deformity 
is  varied  in  several  ways.  The  clonic  spasms  cause  rotary,  or  nodding,  or 
oblique  movements  of  the  head,  elevation  of  the  shoulder,  and  other  movements, 
such  as  throwing  back  of  the  head  and  wrinkling  of  the  forehead  when  both 
trapezii  are  involved,  etc.  The  disease  is  more  common  in  women  than  in 
men,  seldom  occurs  before  the  age  of  thirty,  and  is  sometimes  of  a  traumatic 
or  of  a  distinctly  neurotic  origin.  The  spasms  are  not  attended  by  pain,  but 
are  extremely  distressing  to  the  patient  because  of  inability  to  keep  still,  and 
even,  sometimes,  to  do  any  work.  Mental  depression  is  common.  The  affected 
muscles  usually  become  more  or  less  enlarged  from  continued  use. 

INJURIES   OF   THE   NECK 

Injuries  of  the  neck  are  subcutaneous  injuries  or  open  wounds.  The  most 
important  structures  injured  are  the  blood-vessels,  nerves,  the  air  passages,  the 
esophagus,  the  hyoid  bone  and  the  thoracic  duct. 

Subcutaneous  Injuries  of  the  Neck 

Subcutaneous  injuries  of  the  neck  occur  as  the  result  of  blows  and  falls ; 
further,  from  crushing  injuries — as  when  the  wheel  of  a  vehicle  passes  over  the 
neck,  or  when  the  neck  is  caught  by  a  piece  of  moving  machinery,  or  by  a 
moving  elevator;  as  the  result  of  hanging,  garroting,  and  choking.  Such  in- 
juries are  more  or  less  serious  or  fatal  according  to  the  amount  and  character 
of  the  violence,  the  duration  of  its  application,  and  the  structures  injured.  A 
fatal  asphyxia  may  follow  a  blow  upon  the  larynx  which  causes  no  gross  injury, 
by  spasm  or  paralysis  of  the  muscles  of  the  glottis,  or,  on  the  other  hand,  by 
severe  violence  the  trachea  may  be  completely  torn  across. 

When  an  individual  is  choked  to  death  by  another,  the  prints  of  the  assail- 
ant's fingers  can  usually  be  distinguished  as  scratches,  ecchymoses,  and  livid 
marks  on  the  skin.  When  garroted  by  a  cord,  a  livid  groove  can  be  seen 
entirely  encircling  the  neck.  Hanging,  on  the  other  hand,  usually  does  not 
leave  a  complete  circle  around  the  neck,  showing  the  point  of  application  of 
the  rope,  at  least  in  cases  of  suicide.  In  cases  of  judicial  hanging  the  violence 
is  extreme,  and  the  mark  of  the  rope  may  completely  encircle  the  neck.  The 
presence  of  ecehymosis  in  and  beneath  the  skin  in  the  vicinity  of  such  marks 
indicates  that  the  constriction  took  place  before  death.  Its  absence,  if  a  hard 
cord  or  rope  was  used,  indicates  that  death  was  due  to  other  causes.  In  judicial 
hangings  the  lesions  produced  are  often  severe,  and  include  rupture  of  muscles, 
vessels,  nerves,  and  often  dislocation  of  the  upper  cervical  vertebra?,  frequently 


INJURIES    OF   THE   NECK  535 

of  the  atlas  and  axis,  with  rupture  or  crushing;  of  the  spinal  cord.  In  suicidal 
hangings,  and  murders  by  tying  a  cord  or  other  ligature  about  the  neck,  death 
occurs  from  asphyxia  by  closure  of  the  upper  orifice  of  the  larynx  or  of  the 
trachea  by  direct  compression.  The  hyoid  bone  and  larynx  may  be  fractured. 
In  case  the  strangling  is  clone  with  a  band  of  soft  cloth,  such  as  a  silk  hand- 
kerchief, no  mark  whatever  may  be  left  upon  the  skin.  Sudden  constriction 
of  the  neck  may  cause  rupture  of  the  inner  and  middle  coats  of  the  carotids, 
followed  later,  if  the  patient  survives  the  immediate  effects  of  the  injury,  by 
thrombosis  or  aneurism.  The  immediate  symptoms  of  the  subcutaneous  in- 
juries of  the  neck  involving  injury  of  or  pressure  upon  the  windpipe  are 
dyspnea,  more  or  less  severe,  or  asphyxia.  Subcutaneous  hemorrhage  from 
rupture  of  large  vessels  may  also,  by  pressure,  cause  asphyxia. 

Fracture  of  the  Hyoid  Bone — Fracture  of  the  hyoid  bone  occurs  as  the 
result  of  hanging — judicial,  homicidal,  or  suicidal;  from  grasping  the  throat 
in  fighting,  or  strangling ;  from  a  blow ;  in  rare  instances,  from  muscular  action. 
The  fracture  takes  place  through  the  body  or  greater  cornu.  The  signs  of  frac- 
ture— mobility  and  crepitus — can  usually  be  made  out  through  the  skin  or 
with  a  finger  in  the  mouth.  The  end  of  a  fragment  frequently  perforates 
the  mucous  membrane  of  the  pharynx,  and  profuse  bleeding  is  not  uncommon ; 
a  considerable  hematoma  may  form  in  the  neck.  Subjectively,  there  is  local 
pain  and  tenderness.  The  most  marked  symptoms  are  due  to  interference  with 
swallowing  and  respiration;  any  attempt  to  swallow,  or  even  to  move  the 
tongue  or  jaw,  is  attended  by  intense  pain,  and  often  by  a  paroxysm  of  choking 
and  coughing;  so  that  these  patients  have  sometimes  to  be  fed  through  a  cathe- 
ter or  esophageal  tube.  Speaking  is  also  interfered  with,  and  is  painful ;  there 
may  be  hoarseness  or  aphonia.  The  dyspnea  is  often  marked,  and  may  even 
require  tracheotomy.     Dislocation  of  the  hyoid  bone  has  been  observed. 

Fracture  of  the  Larynx. — The  fractures  of  the  larynx  occur  through  the 
thyroid  and  cricoid  cartilages,  very  rarely  through  the  arytenoid  cartilages. 
The  fractures  are  more  common  in  men  than  in  women,  and  among  the  middle- 
aged  and  elderly  rather  than  the  young.  They  result  chiefly  from  violence 
exerted  from  side  to  side,  tending  to  crush  the  cartilages  of  the  larynx  later- 
ally, or  violence  directed  from  before  backward,  crushing  the  cartilages  against 
the  anterior  surface  of  the  vertebral  column.  The  fractures  are  caused  by 
blows,  falls,  hanging,  strangling,  run-over  injuries,  and  gunshot  wounds.  When 
the  fractures  are  produced  by  lateral  compression  of  the  larynx — as  when  the 
larynx  is  grasped  between  the  fingers  in  the  effort  to  choke  the  individual — the 
fracture  of  the  thyroid  occurs,  usually  near  its  anterior  border  and  in  a  vertical 
direction;  the  ring  of  the  cricoid  is  commonly  broken  at  the  same  time,  some- 
times bilaterally,  sometimes  near  the  middle  line  in  front.  As  the  result  of 
extreme  degrees  of  violence  and  of  gunshot  wounds,  the  cartilages  of  the  larynx 
may  be  more  or  less  disintegrated  and  crushed  to  a  pulp. 

The  signs  of  fracture  are :  Deformity,  which  is  usually  rapidly  hidden  by 
swelling;  but  more  particularly  marked  are  the  signs  of  interference  with  the 


536  THE   NECK 

function  of  the  larynx,  namely,  severe  dyspnea,  which  may  be  almost  imme- 
diately fatal ;  painful  and  paroxysmal  coughing,  caused  by  the  mechanical 
interference  with  respiration,  by  irritation  of  the  larynx  produced  by  the  in- 
jury and  by  the  aspiration  of  blood  into  the  trachea  and  lungs.  Swallowing 
is  painful  and  difficult,  but  this  symptom  is  not  as  marked  as  after  fracture 
of  the  hyoid  bone.  If  the  mucous  membrane  is  torn,  there  is  steadily  pro- 
gressive emphysema,  which  travels  down  the  neck,  involves  the  thorax,  the 
remainder  of  the  trunk,  and  finally  the  extremities,  and  also  extends  down 
the  intermuscular  planes  of  the  neck  into  the  mediastinum,  sometimes  into  the 
pleura,  as  well  as  upward  into  the  face.  The  cough  is  accompanied  by  the  ex- 
pulsion of  foamy  blood  from  the  mouth.  There  are  changes  in  the  voice, 
aphonia,  and  hoarseness.  Death  may  occur  from  asphyxia,  due  to  aspiration 
of  large  quantities  of  blood  into  the  lungs,  from  mechanical  interference  with 
the  passage  of  air  through  the  larynx,  or  later  from  swelling  and  edema  of  the 
mucous  membrane,  which  may  occur  at  once  or  not  come  on  for  a  number  of 
days.  These  dangers  are  best  met  by  an  early  tracheotomy.  In  mild  cases  all 
the  symptoms  will  be  less,  severe. 

Fracture  of  the  Cartilages  of  the  Trachea. — Fracture  of  the  cartilages  of  the 
trachea  is  less  common  than  fractures  of  the  larynx.  It  occurs  usually  as  the 
result  of  severe  crushing  injuries  of  the  neck.  The  trachea  may  be  crushed 
from  before  backward  or  laterally,  or  torn  across,  or  torn  away  from  the  larynx. 
The  symptoms  are  the  same  as  those  of  fracture  of  the  larynx;  emphysema  is 
marked.  The  diagnosis  is  not  easy  on  account  of  the  deep  position  of  the 
trachea,  rendered  still  more  inaccessible  by  the  attendant  swelling  and  emphy- 
sema. 

Burns  of  the  Neck. — Burns  of  the  neck  are  chiefly  interesting  on  account 
of  the  cicatricial  contraction  and  resulting  deformities  which  may  follow  these 
injuries. 

Wounds  of  the  Neck 

Wounds  of  the  neck  occur  most  often  as  incised  and  stab  wounds,  as  the 
result  of  attempts  at  suicide,  less  often  as  the  result  of  homicidal  assaults. 
Contused  and  lacerated  and  gunshot  wounds  are  comparatively  rare.  The 
majority  of  suicidal  wounds  of  the  neck  are  made  with  razors,  carving  knives, 
and  the  like.  They  are  incised  wounds,  usually  in  the  upper  part  of  the  neck. 
In  right-handed  people  they  begin  to  the  left  of  the  middle  line,  and  extend 
across  the  neck  and  downward  to  the  right.  The  wound  is  usually  more 
extensive  to  the  left  of  the  median  line,  and  may  here  exhibit  ragged  tags  of 
skin  or  one  or  more  superficial  parallel  cuts  in  the  skin.  The  cut  may  cross 
the  middle  line  at  any  level,  most  commonly  in  the  space  between  the  hyoid 
bone  and  the  thyroid  cartilage,  or  through  that  cartilage  or  through  the  crico- 
thyroid membrane,  or  more  rarely  below  that  point.  These  wounds  are  of 
any  depth;  they  may  open  the  pharynx  or  larynx  or  trachea,  or  divide  these 
structures  and  the  esophagus,   together  with  numerous  vessels,   muscles,   and 


INJURIES    OF   THE   NECK  537 

nerves.  Usually  the  carotids  and  internal  jugulars  escape,  on  account  of  the 
protection  afforded  by  the  sterno-mastoids  and  the  deep  position  of  these  vessels 
when,  as  is  usual,  the  individual  extends  his  neck  when  making  the  cut.  More 
rarely,  suicidal  wounds  are  stabs  intended  to  reach  the  large  vessels.  Homi- 
cidal wounds  are  usually  stabs  or  incised  wounds  on  the  side  of  the  neck. 

Suicidal  gunshot  wounds  of  the  neck  are  rare.  I  saw  one  case  in  which 
a  young  man  shot  himself  with  a  .22  caliber  pistol  directly  backward  through 
the  upper  rings  of  the  trachea.  Aside  from  cough  and  bloody  expectoration, 
some  pain  on  swallowing,  and  subcutaneous  emphysema  of  the  neck,  there  were 
no  serious  symptoms,  and  he  made  a  prompt  recovery.  The  gravity  of  incised 
wounds  of  the  neck  depends  upon  hemorrhage,  upon  injuries  to  the  air  passages 
and  esophagus,  the  nerves  and  muscles ;  further,  upon  aspiration  of  blood  into 
the  lungs,  causing  dyspnea  or  asphyxia ;  later,  aspiration  of  wound  discharges 
or  food,  and  septic  pneumonia,  are  common;  further,  upon  wound  infection 
and  sepsis.  If  the  wound  is  above  the  hyoid  bone,  and  divides  the  muscles 
supporting  the  tongue,  that  organ  may  fall  back  upon  the  larynx  and  cause 
asphyxia. 

I  saw  another  gunshot  wound  of  the  neck,  where  a  man  was  shot  by  another 
with  a  .22  caliber  revolver,  through  the  middle  of  the  thyroid  cartilage.  The 
bullet  apparently  had  passed  directly  backward.  The  patient  suffered  from 
scarcely  any  noteworthy  symptoms  other  than  hoarseness,  and  was  soon  en- 
tirely well.  In  another  case,  recently  under  my  care,  a  man  cut  his  wife's 
throat  with  a  razor  in  a  fit  of  jealous  rage,  also  wounding  her  in  other  parts 
of  the  body.  The  wound  in  the  neck  was  transverse,  and  extended  across  the 
neck  from  ear  to  ear  at  the  level  of  the  thyro-hyoid  space,  and  opened  the 
pharynx  at  this  level  for  about  an  inch.  The  patient  had  bled  rather  freely, 
but  suffered  no  other  serious  symptoms.  Suture  of  the  hole  in  the  pharynx 
and  of  the  divided  muscles  was  followed  by  primary  union.  In  several  other 
cases,  which  I  have  seen,  chiefly  elderly  lunatics  who  cut  themselves  in  the 
throat  with  a  razor,  the  pharynx  has  been  widely  opened;  and,  since  these 
patients  managed  to  tear  off  the  dressings  from  time  to  time,  and  the  openings 
in  the  pharynx  were  large,  the  wounds  became  infected  and  the  patients  died 
of  septic  pneumonia.      (See,  also,  Esophagus.) 

Injuries  of  Blood-vessels  of  the  Neck  in  General. — The  most  serious  symp- 
toms of  wounds  of  the  neck  are  due  to  bleeding.  If  the  wound  is  widely  open, 
and  neither  the  air  passages  nor  the  pleura  are  injured,  the  blood  escapes  out- 
wardly. If  the  pharynx,  larynx,  trachea,  or  pleura  are  wounded,  and  more 
especially  if  the  wound  in  the  skin  is  small,  much  of  the  blood  may  enter  the 
trachea  and  cause  dyspnea,  etc.,  or  find  its  way  into  the  pleura,  or  form  a  more 
or  less  extensive  hematoma  in  the  subcutaneous  tissues  and  intermuscular  planes 
of  the  neck,  with  serious  or  fatal  pressure  symptoms  upon  the  larynx  or 
trachea.  Such  pressure  may,  however,  act  to  stop  the  bleeding,  even  from  a 
large  vessel,  notably  if  it  be  not  completely  divided  or  the  wound  in  its  wall 
be  longitudinal ;  the  hematoma  may  then  be  absorbed  and  cure  result.     In  other 


538  THE   NECK 

cases  infection  of  the  hematoma  exposes  the  individual  to  the  dangers  of  sepsis 
and  secondary  hemorrhage.  Further,  the  wound  in  the  skin  may  heal,  the 
wound  of  the  artery  may  remain  open,  and  an  aneurism  may  result. 

It  is  very  important  in  wounds  of  the  neck  to  determine  the  source  of  the 
bleeding — i.  e.,  what  vessel  is  wounded.  In  incised  wounds  this  is  not  diffi- 
cult ;  the  wound  lies  open  to  inspection.  In  narrow  stab  and  punctured  wounds 
and  in  gunshot  wounds  the  conditions  are  not  so  simple,  and  the  surgeon  may 
be  deceived  as  to  the  gravity  of  the  condition,  notably  if  some  time  has  elapsed 
since  the  receipt  of  the  injury.  The  bleeding  from  a  large  vessel,  artery,  or 
vein  may  have  been  free  at  first,  but  with  a  considerable  loss  of  blood  and  a 
weakened  pulse ;  a  small,  continuous  hemorrhage  of  no  great  amount  may,  never- 
theless, represent  the  division  of  a  large  arterial  trunk.  If  such  a  trunk  is  only 
partly  divided,  a  systolic  blowing  murmur  may  sometimes  be  heard  on  auscul- 
tation. The  formation  of  an  arterial  hematoma  which  showed,  after  a  time, 
pulsation  and  a  murmur,  would  indicate  a  similar  injury.  Absence  of  a  tem- 
poral pulse  in  the  presence  of  stab  wound  in  the  region  of  the  common  or 
external  carotid  would  indicate  division  of  one  or  other  of  these  vessels,  and 
a  stab  wound  behind  the  clavicle  would,  in  the  absence  of  a  radial  pulse,  indi- 
cate a  division  of  the  subclavian,  but  in  neither  case  with  any  certainty.  Surer 
and  more  satisfactory  diagnostic  measures  are  exposure  of  the  bleeding  point 
through  a  suitable  incision,  using  the  original  wound  as  a  guide. 

Injuries  of  the  Particular  Vessels. — The  innominate  artery  may  be  injured 
by  gunshot  wounds  or  by  stab  wounds  at  the  root  of  the  neck.  The  results  are 
almost  immediate  death  from  external  or  intrathoracic  hemorrhage.  Wounds 
of  the  subclavian  are  rare  on  account  of  the  protected  position  of  the  vessel. 
Stab  and  gunshot  wounds  have  been  the  cause  of  the  injury  in  the  recorded 
cases.  In  most  instances  rapidly  fatal  bleeding  has  occurred  before  aid  could 
be  rendered.  In  other  cases  an  aneurism  has  formed,  and  resulted  fatally 
from  one  cause  or  another.  The  vein  and  the  pleura  are  often  wounded  to- 
gether with  the  artery. 

The  common  carotid  artery  is  wounded  much  more  often  than  the  sub- 
clavian ;  in  not  a  few  cases  as  the  result  of  suicidal  cuts ;  in  these  cases  near 
its  upper  part,  opposite  the  level  of  the  larynx.  When  completely  divided, 
death  from  hemorrhage  is  almost  immediate.  If  the  wound  is  a  stab  or  punc- 
ture a  fatal  result  may  occur  from  the  pressure  of  the  effused  blood  upon  the 
trachea.  Less  commonly  the  bleeding  may  cease  and  a  cure  result.  The  ex- 
ternal and  internal  carotids  are  much  more  rarely  wounded  as  the  result  of 
stab  and  gunshot  wounds  of  the  side  of  the  neck,  in  some  cases  from  the 
interior  of  the  mouth.  The  bleeding  is  rapidly  fatal  unless  controlled  at  once. 
The  bleeding  points,  on  account  of  the  narrow  space  behind  the  jaw,  are  rather 
inaccessible.  The  branches  of  the  external  carotid  may  be  wounded  in  cut- 
throat cases,  often  several  branches  at  the  same  time.  The  bleeding  is  severe, 
and  often  speedily  fatal  if  not  controlled  surgically.  Wounds  of  the  superior 
thyroid  and  of  the  thyroid  gland  itself  bleed  furiously.     Wounds  of  the  verte- 


INJUKIES    OF   THE   NECK  539 

bral  artery  are  riot  exceedingly  rare,  and  are  even  more  fatal  than  wounds 
of  the  common  carotid,  largely  on  account  of  the  inaccessible  position  of  the 
vessel.  The  artery  may  be  wounded  in  any  part  of  its  course  by  a  gunshot 
wound.  Stab  wounds  are  most  common  in  the  upper  part  of  the  vessel,  near 
the  atlas.  The  external  wound  may  be  in  the  back  of  the  neck,  or  below  and 
behind  the  mastoid  process.  When  the  wound  is  in  front  it  may  be  hard  to 
tell  whether  the  vertebral  or  the  carotid  is  injured.  Search  may  be  made  for 
the  so-called  carotid  tubercle  on  the  transverse  process  of  the  sixth  cervical 
vertebra,  and  pressure  made  backward,  first  above  and  then  below  the  tubercle. 
If  pressure  below  the  tubercle  stops  the  bleeding,  the  vertebral  is  probably 
wounded;  if  pressure  above  checks  it,  the  carotid,  because,  above  the  sixth 
cervical  vertebra,  the  vertebral  is  protected  by  the  transverse  processes  of  the 
upper  vertebrae  as  it  passes  upward  through  the  holes  in  these  processes. 

Wounds  of  Veins  of  the  Neck. — Wounds  of  large  veins  in  the  neck  are  easy 
to  recognize ;  the  blood  streams  out  steadily  and  rapidly,  and  in  the  case  of  the 
internal  jugular  is  capable  of  causing  rapid  death  from  loss  of  blood  quite  as 
quickly  as  from  division  of  a  large  arterial  trunk.  The  same  is  true  to  even 
a  greater  extent  of  the  innominate  vein  and  of  the  subclavian  vein.  Open 
wounds  communicating  directly  with  these  vessels  are  speedily  fatal  unless 
treated.  If  the  wound  in  the  skin  is  small  so  that  the  blood  cannot  freely 
escape,  a  hematoma  may  form  and  cause  dyspnea  or  death  from  pressure.  In 
conditions  which  interfere  with  the  entrance  of  blood  through  the  veins  into 
the  thorax,  such  as  dyspnea  from  laryngeal  obstruction  or  by  pressure  upon 
large  veins  at  the  entrance  to  the  thorax  by  tumors  or  exudates,  venous  hemor- 
rhage may  be  greatly  increased,  the  veins  are  distended  with  blood,  and,  when 
wounded,  the  aspirating  effect  of  the  thorax  being  diminished  or  wanting, 
bleeding  is  very  active. 

Another  accident,  fortunately  quite  rare,  is  the  aspiration  of  air  into  open 
wounds  of  the  veins  at  the  root  of  the  neck.  It  is  more  apt  to  occur  in  widely 
open  wounds,  such  as  are  made  in  surgical  operations,  than  from  stab  wounds 
or  other  narrower  wounds.  The  symptoms  of  such  entrance  of  air  are  a  dis- 
tinctly audible  sucking  or  gurgling  sound,  caused  by  the  rapid  passage  of  air 
through  the  opening  in  the  vein,  and,  in  cases  where  the  amount  of  air  is  con- 
siderable, almost  instantaneous  stoppage  of  the  heart,  and  death.  In  some 
cases  the  general  symptoms  may  be  postponed  for  several  minutes.  The  patient 
then  becomes  very  pale  and,  if  conscious,  has  a  feeling  of  intense  anxiety  and 
of  choking;  respiration  becomes  labored,  the  pulse  rapid  and  fluttering;  the 
pupils  dilate;  there  may  be  convulsive  movements,  syncope,  and  death.  Any 
of  the  large  veins  at  the  root  of  the  neck,  if  wounded,  may  aspirate  air  in  this 
manner,  especially  the  internal  jugular,  the  external  jugular  where  it  per- 
forates the  deep  fascia,  the  innominate,  the  subclavian  and  axillary  veins.  Air 
may  also  enter  much  smaller  veins  if  they  are  held  open  by  attachments  to 
fascia  or  by  inflammatory  exudates,  or  when  the  wall  of  the  vein  is  thickened 
or  rigid,  as  from  infiltration  with  tumor  tissue,  so  that  they  cannot  collapse 


540  THE   NECK 

when  wounded.  Fortunately,  in  a  good  many  cases,  even  though  considerable 
air  has  entered,  there  are  either  no  symptoms,  or  such  symptoms  as  arise 
are  recovered  from,  the  air  being  absorbed.  Personally,  although  I  have  seen 
and  heard  air  enter  veins  on  several  occasions,  no  serious  symptoms  have 
followed. 

Injuries  of  the  Nerves  of  the  Neck  in  General. — Injuries  of  the  nerves  of 
the  neck  occur  as  the  result  of  crushing  injuries,  as  a  complication  of  frac- 
tures of  the  clavicle,  and  from  incised,  stab,  and  gunshot  wounds ;  secondarily, 
from  pressure  by  displaced  fragments  of  bone  or  from  callus  production,  from 
the  pressure  of  tumors  or  masses  of  cicatricial  tissue  or  foreign  bodies.  In- 
juries of  the  cervical  and  brachial  plexuses  of  nerves  occur  most  often  as  the 
result  of  blunt  violence  applied  to  the  side  of  the  neck,  sometimes  associated 
with  fracture  of  the  clavicle.  Less  often,  one  or  more  of  the  cords  of  the 
cervical  or  brachial  plexus  may  be  divided  in  incised,  stab,  and  gunshot  wounds. 
The  symptoms  will  vary  according  to  the  extent  and  location  of  the  injury. 
The  crushing  injuries  by  blunt  violence  may  merely  contuse  or  stretch  the 
nerves,  or  destroy  one  or  more  trunks  completely.  I  have  seen  several  cases 
in  which,  from  blows  and  falls  upon  the  shoulder  and  neck,  without  any 
external  wound,  the  functions  of  nearly  all  the  nerves  of  the  brachial  plexus 
were  totally  and  permanently  destroyed.  The  anatomical  site  of  the  plexus 
was  occupied  by  a  dense  mass  of  cicatricial  tissue  in  which  no  nerve  elements 
could  be  traced.     (See,  also,  Injuries  of  the  Upper  Extremity.) 

In  the  different  cases,  from  whatever  cause,  the  paralytic  symptoms,  motor 
and  sensory,  will  vary  according  to  the  seat  and  extent  of  the  lesion.  At  the 
time  of  the  injury  there  is  generally  severe  pain;  the  paralyses  due  to  nerve 
destruction  are  present  at  once.  In  cases  of  contusion  of  the  nerves  merely, 
the  paralysis  may  be  incomplete,  and  be  accompanied  by  symptoms  of  irritation 
— twitching  of  certain  muscles,  paresthesia?,  neuralgic  pains,  and  disturbances 
of  sensibility  without  complete  anesthesia.  Usually  the  motor  paralysis  is 
more  complete  than  the  sensory.  If  the  nerve  trunks  have  been  entirely 
divided  or  destroyed,  the  paralysis  is  permanent.  In  certain  cases,  after  the 
paralysis  has  existed  for  a  certain  time  a  traumatic  neuritis  may  be  developed 
in  the  injured  nerve  trunks,  and  may  spread  to  other  nerves  which  anastomose 
with  those  which  have  been  injured.  There  will  then  be  added .  pain  and 
further  paralyses  affecting  the  uninjured  nerves  the  seat  of  neuritis. 

In  some  cases — notably  those  produced  by  the  pressure  of  bony  fragments, 
by  callus  production,  by  the  presence  of  foreign  bodies,  or  the  development  of 
masses  of  cicatricial  tissue  which  press  upon  the  nerve  trunks,  the  paralysis 
will  tend  to  be  more  marked  as  the  pressure  increases.  In  these  cases,  also,  a 
neuritis  may  be  developed  as  the  result  of  pressure.  As  the  result  of  permanent 
loss  of  function  in  the  nerves  there  will  be  developed  atrophic  and  degenerative 
changes  in  the  muscles,  and  trophic  changes  in  the  skin  of  the  extremity,  such 
as  have  already  been  described  under  Injuries  of  Nerves.  It  is  generally 
impossible  to  say  in  the  given  case,  without  operative  exposure  of  the  injured 


INJURIES    OF   THE   NECK  541 

nerves,  to  what  extent  regeneration  of  the  injured  nerve  trunks  will  take 
place.  I  saw  one  case  of  a  stab  wound  high  up  in  the  axilla,  which  divided 
all  the  cords  of  the  brachial  plexus;  the  atrophy  of  the  arm  was  complete  and 
permanent ;  in  spite  of  several  carefully  planned  operations  for  the  restoration 
of  the  divided  nerves,  no  return  of  function  followed.  (See  Injuries  of 
Nerves,  Vol.  III.) 

Injuries  of  the  Individual  Nerves  of  the  Neck. — Injuries  of  the  Pneumogas- 
tric Nerve. — The  pneumogastric  nerve  is  occasionally  wounded  or  pinched  by 
an  artery  clamp  or  a  ligature  during  surgical  operations  upon  the  neck,  notably 
in  the  extirpation  of  tumors,  rarely  ligation  of  the  common  carotid  artery.  In 
operations  upon  the  thyroid  gland  the  recurrent  laryngeal  nerve  may  be  torn 
or  pinched,  or  included  in  the  ligature  surrounding  the  inferior  thyroid 
artery.  Fractures  of  the  base  of  the  skull  sometimes  injure  the  pneumogas- 
tric. There  may  be  an  associated  lesion  of  the  glosso-pharyngeal.  Division 
of  the  pneumogastric  nerve  of  one  side  in  the  neck  will  produce  symptoms 
which  appear  to  be,  in  most  instances  at  least,  grave  dangers  to  life.  If 
the  nerve  is  merely  pinched  with  an  artery  clamp,  sudden  symptoms  of  collapse 
may  occur,  such  as  sudden  failure  of  respiration  or  of  the  heart  action.  In 
the  reported  cases  these  symptoms  have,  however,  disappeared  when  pressure 
upon  the  nerve  ceased  or  suitable  stimulation  and  artificial  respiration  were 
used.  Division  of  the  nerve  does  not  appear  to  affect  the  pulse  or  respiration 
materially,  although  in  some  cases  a  rapid  pulse  has  been  observed  for  a  time. 
Its  accidental  or  intentional  division  has  usually  occurred  during  the  removal 
of  malignant  growths  of  the  neck ;  and  although  death  has  followed  in  about 
half  the  cases,  it  has  seemed  to  be  due  to  causes  other  than  the  injury  to  the 
nerve.  The  only  constant  symptoms  are  due  to  the  division  of  the  fibers  be- 
longing to  the  recurrent  laryngeal  nerve,  namely,  paralysis  of  one  vocal  cord 
and  the  resulting  hoarseness  or,  in  some  cases,  aphonia. 

Division  of  the  pneumogastric  above  the  origin  of  the  superior  laryngeal 
nerve  causes,  in  addition,  anesthesia  of  the  corresponding  half  of  the  larynx. 
Division  of  both  pneumogastrics  in  the  neck  causes  total  paralysis  of  both 
vocal  cords,  a  rapid  pulse,  changes  in  the  breathing — either  increased  or  dimin- 
ished frequency — and  death  from  edema  of  the  lungs  or  pneumonia.  Irritation 
of  the  pneumogastrics  causes,  as  its  most  notable  symptom,  a  slow  pulse. 

Injury  of  the  Sympathetic  Cord  in  the  Neck. — Division  of  the  cervical 
sympathetic  scarcely  occurs  as  an  isolated  accidental  injury.  As  an  associated 
injury  it  has  been  occasionally  observed.  Paralysis  is  more  often  due  to 
pressure  from  tumors.  In  one  case  of  my  own  it  appeared  to  be  accompanied 
by  fibrous  thickening  of  the  sheath  of  the  nerve,  and  was  associated  with  tri- 
geminal and  occipital  neuralgia.  The  symptoms  of  paralysis  of  the  cervical 
sympathetic  are  slight  sinking  in  of  the  eyeball,  loss  of  the  cilio-spinal 
reflex,  a  contracted  pupil  on  the  affected  side,  partial  ptosis,  flushing  of 
half  the  face,  an  increase  in  temperature,  and  sometimes  sweating  of  the 
skin  of  the  face  on  the  affected  side.     Irritation  of  the  cervical  sympathetic 


542  THE   NECK 

causes  a  dilated  pupil,  sometimes  exophthalmos  and  elevation  of  the  upper  lid 
so  that  the  eye  appears  prominent  and  larger,  paleness  and  coldness  of  the 
corresponding  side  of  the  face. 

The  Hypoglossal  Nerve. — The  hypoglossal  nerve  may  be  injured  in  cut- 
throat cases,  and  rarely  in  surgical  operations  by  carelessness.  I  have  seen  a 
ligature  put  around  it  by  a  gentleman  who  was  seeking  the  lingual  artery. 
The  symptoms  produced  by  its  division  are  unilateral  motor  paralysis  of  the 
tongue.     In  some  cases  hemiatrophy  of  the  tongue. 

Division  of  the  Phrenic  Nerve. — Division  of  the  phrenic  nerve  causes 
paralysis  of  one  half  of  the  diaphragm ;  division  of  both  phrenics,  immediate 
death  by  respiratory  failure.  The  division  of  one  phrenic  is  followed  by  one 
notable  symptom — i.  e.,  dyspnea  on  exertion.  Death  has  occurred  in  a  few 
cases  (ligation  of  third  part  of  the  subclavian).  Irritation  of  the  phrenic 
causes  spasmodic  coughing  and  hiccough. 

Division  of  the  Spinal  Accessory  Nerve. — Division  of  the  spinal  accessory 
nerve  in  front  of  the  sterno-mastoid  behind  the  angle  of  the  jaw  causes  some- 
times paralysis  of  the  sterno-mastoid  and  trapezius  muscles,  followed  by  atrophy. 
In  other  cases  the  latter  muscle  receives  a  sufficient  innervation  from  other 
sources  and  retains  its  function  wholly  or  partly.  When  paralysis  and  atrophy 
follow  the  division  of  the  nerve,  the  unopposed  action  of  the  muscles  of  the 
opposite  side  causes  a  more  or  less  marked  paralytic  wry-neck.  The  shoulder 
droops,  and  with  the  scapula  falls  forward.  The  power  of  lifting  heavy 
weights  is  lost.     (See  Injuries  of  the  Upper  Extremity.) 

The  Posterior  Thoracic  Nerve,  Supplying  the  Serratus  Magnus  Muscle. — 
The  posterior  thoracic  nerve  is  occasionally  injured  alone  by  injuries  in  the 
neighborhood  of  the  shoulder,  and  is  sometimes  cut  accidentally  during  opera- 
tions in  the  axilla,  especially  during  the  complete  operations  for  carcinoma 
of  the  breast.  The  resulting  paralysis  causes  the  scapula  to  hang  backward 
and  to  flare  away  from  the  chest  wall  in  a  characteristic  manner.  (See  Upper 
Extremity.) 

Injuries  of  the  Thoracic  Duct. — Injuries  of  the  thoracic  duct  are  exceedingly 
rare  as  isolated  accidental  injuries,  and  are  usually  complicated  by  wounds  of 
the  neighboring  blood-vessels  so  that  the  signs  cf  injury  of  the  duct  are  over- 
shadowed by  bleeding  and  other  symptoms.  Wounding  of  the  duct  near  its 
ordinary  point  of  entrance  into  the  angle  between  the  left  subclavian  and 
internal  jugular  veins  is  by  no  means  uncommon  during  the  extirpation  of 
tumors  and  tuberculous  lymph  nodes  at  the  root  of  the  neck.  The  injury  is 
to  be  recognized  by  the  escape  of  abundant,  more  or  less  turbid  or  milky  white 
fluid  into  the  wound  and  the  recognition  of  the  slit  or  puncture  in  the  wall 
of  the  duct.  I  have  seen  this  accident  happen  four  times.  In  three  cases  the 
opening  was  successfully  closed  by  suture;  in  the  fourth  case  (one  of  car- 
cinomatous glands  in  the  subclavian  triangle)  I  sutured  the  slit  in  the  duct 
twice  unsuccessfully,  and  finally  applied  a  firm  pad  in  the  supraclavicular 
region,  under  which  the  wound  in  the  duct  healed. 


INFLAMMATORY   PROCESSES    OF   THE   NECK  543 

Wounds  of  the  Esophagus. — Wounds  of  the  esophagus  rarely  occur  alone 
as  the  result  of  external  wounds;  other  important  structures  arc  commonly 
injured.  If  the  wound  is  a  widely  opened,  incised  wound,  the  diagnosis  can 
be  made  by  inspection ;  otherwise  the  recognition  of  the  condition  must  depend 
upon  the  symptoms,  often  not  clear.  Such  symptoms  are,  in  typical  cases,  pain 
and  difficulty  in  swallowing,  regurgitation  of  food  or  vomiting  of  blood,  and  the 
escape  of  mucus,  or  of  solids  or  fluids  swallowed,  from  the  external  wound. 
The  lower  the  position  of  the  wound  the  greater  the  danger  of  the  escape  of 
infectious  material  into  the  mediastinum  or  pleura,  to  be  followed  by  a  septic 
mediastinitis,  or  pleuritis  and  death.  The  esophagus  may  be  wounded  from 
within  by  sharp  foreign  bodies  swallowed,  and  if  these  become  impacted,  they 
also  may  ulcerate  into  the  pleura,  mediastinum,  or  trachea,  and  cause  septic 
inflammation,  or,  if  into  the  trachea,  strangulation  or  septic  pneumonia.  (For 
further  details,  see  Esophagus.)  Severe  hemorrhage  may  occur  from  ruptured 
varicose  veins  of  the  esophagus,  spontaneously  or  as  the  result  of  vomiting, 
notably  in  drunkards.  I  have  a  patient  who  has  twice  nearly  bled  to  death  in 
this  manner.  I  have  had  him  under  observation  for  fifteen  years.  The  symp- 
toms are  vomiting  of  blood.  As  the  result  of  violent  vomiting  in  such  cases 
the  esophagus  may  be  ruptured  near  the  cardia,  with  fatal  results.  (See 
Diseases  of  the  Esophagus.) 

Burns  of  the  Esophagus. — Swallowing  hot  liquids,  strong  acids,  and  alkalies, 
and  notably  carbolic  acid,  causes  burns  of  the  esophagus  of  greater  or  less 
severity.  The  symptoms  of  such  burns  and  the  extent  of  the  injury  vary 
according  to  the  character,  quantity,  and  concentration  and  temperature  of  the 
liquid  swallowed.  In  bad  cases  the  mucous  membrane  of  the  mouth,  throat, 
esophagus,  and  stomach  are  deeply  destroyed.  Speedy  death  from  shock  is 
not  rare  in  these  cases.  Perforation  of  the  stomach,  and  death  from  peri- 
tonitis or  infection  and  phlegmonous  inflammation  of  the  wall  of  the  stom- 
ach, are  not  infrequent.  In  the  less  severe  cases  the  signs  and  symptoms 
are,  evidences  of  burns  in  the  mouth  and  pharynx,  pain  in  the  esophagus 
and  stomach,  vomiting,  retching,  hiccough,  inability  to  swallow,  and  pros- 
tration; sometimes  edema  of  the  glottis.  Wounds  and  burns  of  the  esophagus 
are  quite  commonly  followed  by  stricture.  (See  Injuries  and  Diseases  of 
the  Esophagus.) 

INFLAMMATORY  PROCESSES   OF   THE   NECK 

The  Tissues  of  the  Neck. — Acute  and  chronic  inflammatory  processes  of  the 
most  varied  character  occur  in  the  tissues  of  the  neck  with  great  frequency. 
The  anatomical  arrangement  of  the  fascial  and  connective-tissue  planes  of  the 
neck  is  such  that  suppurating  foci  in  certain  situations  advancing  along  the 
lines  of  least  resistance  tend  to  spread  in  definite  ways.  The  arrangement  of 
the  lymphatics  of  the  neck,  also,  has  an  important  bearing  on  the  successvie 
involvement  of  different  areas. 


544 


THE   NECK 


The  following  anatomical  details  are  adapted  from  Merkel's  "  Toj)Ograph- 
ical  Anatomy  " :  The  skin  of  the  neck  is  firmly  adherent  to  the  platysma 
rnyoides,  any  inflammatory  focus  in  the  substance  of  the  skin,  and  superficial 
to  the  platvsma,  tends  to  remain  distinctly  localized.  Beneath  the  platysma 
is  a  layer  of  loose  connective  tissue;  a  purulent  focus  in  this  layer  may  spread 
up  and  down  the  neck,  even  on  to  the  thorax,  but  shows  no  marked  tendency 
to  invade  the  deeper  structures  except  through  the  lymphatics. 


Trachea 


M.  trapezius 


Fettpolster 


Flex,  brachial. 


M.  sternoclm. 


Aponeurose 


M.  subcutan. 
Jugular. 
Gl.  lymphat. 


Carotis 


Gl.  thyr 


Fig.  191. — A  Horizontal  Section  of  the  Neck  at  the  Level  of  the  Uppermost  Ring  of  the 
Trachea,  Showing  the  Fascial  Layers  of  the  Neck.  *  indicates  the  fibrous  layer  which  in- 
cludes the  vertebral  artery.  The  delicate  connective-tissue  planes  which  overlie  the  sternocleido- 
mastoid muscle  and  the  trapezius  are  designated  by  broken  lines.  The  pneumogastric  nerve 
which  lies  behind  the  carotid  and  the  hypoglossal  nerve  which  passes  in  front  of  it  are  not  indicated. 
(Merkel  topographical  anatomy.) 


Merkel  distinguishes  a  deep  fascia  of  the  neck  and  a  separate  aponeurotic 
layer  covering  the  muscles.  The  deep  fascia  is  a  connective-tissue  sheath  which 
covers  the  prevertebral  muscles,  and  in  the  lateral  region  of  the  neck  passes 
into  the  connective-tissue  sheath  of  the  great  vessels.  The  "  neck  aponeurosis  " 
is  a  firm  layer  of  connective  tissue  extending  from  the  hyoid  bone  to  the 
sternum  and  clavicle.  It  is  inserted  into  the  sternum  by  two  lamellae,  an  ante- 
rior and  a  posterior,  to  the  anterior  and  posterior  borders  of  the  sternum 
respectively,  inclosing  a  small  space  filled  with  loose  connective  tissue — "the 


INFLAMMATORY   PROCESSES    OF   THE   NECK  545 

suprasternal  intra-aponeurotic  space."  Purulent  foci  in  this  space  remain 
localized.  The  aponeurosis  covers  the  muscles  attached  to  the  hyoid  bone  in 
the  middle  line.  Laterally,  above  the  tendinous  portion  of  the  middle  of  the 
omohyoid  muscle,  it  passes  into  and  is  lost  in  the  sheath  of  the  great  vessels. 
Below  this  point  it  surrounds  the  omohyoid.  Laterally  this  layer  passes 
beneath  the  sheath  of  the  sterno-mastoid.  The  great  vessels  lie  immediately 
beneath  this  layer.  The  vein  alone  is  intimately  adherent  to  the  apneurosis. 
The  arteries,  nerves,  and  lymph  vessels  are  surrounded  by  a  layer  of  loose 
connective  tissue,  attached  posteriorly  to  the  spinal  column,  and  passing  into 
the  deep  or  prevertebral  fascia.  Above  the  hyoid  bone  there  is  a  firm  layer  of 
connective  tissue  passing  from  the  lower  border  of  the  jaw,  and,  laterally,  cov- 
ering the  sterno-mastoid  muscle.  This  layer  forms  the  so-called  connective- 
tissue  capsule  of  the  submaxillary  gland. 

Between  the  various  fascial  layers  of  the  neck,  and  in  relation  with  the 
blood-vessels,  the  trachea,  and  the  esophagus,  are  certain  planes  of  loose  con- 
nective tissue,  the  primary  purpose  of  which  is  to  permit  that  free  mobility 
necessary  to  enable  the  various  structures  to  move  easily  in  carrying  out  the 
complex  and  varied  motions  of  the  head  and  neck.  These  spaces  are  five  in 
number:  First,  the  retrovisceral  space.  Second,  the  previsceral  space.  Third, 
the  space  for  the  vessels.  Fourth,  the  suprasternal  intra-aponeurotic  space. 
Fifth,  the  capsule  of  the  submaxillary  gland. 

First. — The  retrovisceral  space  lies  between  the  pharynx  and  esophagus  in 
front,  and  the  anterior  surface  of  the  spinal  column  behind.  It  begins  above, 
at  the  base  of  the  skull,  and  extends  downward  into  the  thorax,  as  far  as  the 
ninth  or  tenth  dorsal  vertebra.  Laterally  it  extends  outward  as  far  as  the 
sheath  of  the  vessels.  Second. — The  'previsceral  space  lies  between  the  ante- 
rior surface  of  the  trachea  and  the  muscles  which  ascend  to  be  attached  to  the 
hyoid  bone,  it  is  covered  in  front  by  the  aponeurotic  layer  already  described; 
extends  downward  into  the  anterior  mediastinum  and  reaches  laterally  as  far 
as  the  sheath  of  the  vessels.  The  sheath  of  the  vessels  on  either  side  forms  the 
boundary  between  the  anterior  and  posterior  space.  Third. — The  space  sur- 
rounding the  great  vessels  is  very  important  in  relation  to  the  extension  of 
the  inflammatory  processes  on  account  of  the  great  number  of  lymphatic  glands 
and  channels  wdiich  it  contains,  and  the  rather  firm  character  of  its  connective- 
tissue  boundaries,  which  tend  to  limit  the  spread  of  infectious  processes,  so  that 
they  rather  extend  within  the  sheath  itself  toward  the  mediastinum  than  spread 
into  the  surrounding  tissues.  Fourth. — The  suprasternal  space  extends  from 
the  sternum  upward  as  far  as  the  isthmus  of  the  thyroid.  Fifth. — The  sub- 
maxillary space  exists  because  the  submaxillary  gland  does  not  completely  fill 
the  submaxillary  triangle  formed  by  the  bellies  of  the  digastric  and  the  border 
of  the  jaw.  A  small  space  exists  both  in  front  of  and  behind  the  gland,  filled 
with  loose  connective  tissue,  containing  fat.  The  posterior  border  of  the  mylo- 
hyoid muscle  extends  posteriorly  into  this  space.  The  space  is  bounded  out- 
wardly by  a  dense  layer  of  connective-tissue  covering  in  the  gland,  and  extend- 
36 


546  THE  KECK 

ing  from  the  border  of  the  jaw  to  the  hyoid  bone.  Internally  this  connective- 
tissue  layer  is  attached  to  the  wall  of  the  pharynx,  to  the  tonsil,  and  to  the 
sublingual  giand. 

The  important  facts  to  be  remembered  in  regard  to  these  spaces  are  that  the 
anterior  and  posterior  spaces — previsceral  and  retrovisceral,  respectively,  and 
the  space  surrounding  the  vessels — communicate  freely  below  with  the  thorax, 
and  thus  with  one  another.  Above  the  arch  of  the  aorta  the  trachea  passes 
backward  from  the  anterior  to  the  posterior  space,  so  that  an  infectious  process 
extending  down  the  trachea  may  find  its  way  into  both  anterior  and  posterior 
mediastina.  It  is  also  to  be  remembered  that  suppurative  processes  in  the  neck 
may  extend  along  the  sheaths  of  both  vessels  and  nerves  downward  and  outward 
into  the  axilla.  The  platysma  and  the  skin  being  closely  attached,  and  form- 
ing together  a  firm  dense  layer,  afford  considerable  resistance  to  the  outbreak 
of  deep-seated  suppurative  processes  through  the  skin  in  the  lateral  regions  of 
the  neck. 

The  Lymph  Glands  of  the  Neck. — The  lymphatic  glands  of  the  neck  may  be 
divided  into  several  groups:  First. — The  submaxillary  lymphatics,  quite  numer- 
ous and  scattered  throughout  the  tissues  of  the  submaxillary  triangle.  One 
or  more  is  usually  found  along  the  border  of  the  jaw,  and  a  number  exist  in  the 
loose  connective  tissue  between  the  jaw  and  the  mylohyoid  muscle.  A  few  are 
found  inside  the  capsule  of  the  gland,  but  not  in  the  gland  itself.  These  lym- 
phatics receive  the  lymph  from  the  face,  from  the  interior  of  the  mouth,  the 
teeth,  the  jaw,  the  tongue,  and  the  pharynx.  Second. — The  submental  lym- 
phatics, few  in  number.  They  lie  in  the  connective  tissue  beneath  the  chin. 
They  receive  the  lymph  from  the  lower  lip,  the  chin,  and  the  anterior  portion 
of  the  tongue,  and  are  frequently  the  first  glands  to  become  enlarged  in  can- 
cers and  other  infectious  processes  of  these  regions.  They  empty  into  the  sub- 
maxillary lymphatics.  Third. — The  superficial  cervical  lymph  glands.  These 
glands,  five  or  six  in  number,  lie  upon  the  surface  of  the  sterno-mastoid  muscle 
and  along  its  posterior  border.  They  are  covered  by  the  platysma,  and  receive 
the  lymph  from  the  skin  of  the  neck,  the  nape  of  the  neck,  and  the  external  ear. 
They  communicate  with  the  deep  chain  of  lymphatics.  They  are  often  en- 
larged during  the  early  stages  of  secondary  syphilis.  Fourth.^The  deep 
cervical  lymph  nodes  are  numerous,  fifteen  to  twenty  in  number.  They  extend 
along  the  course  of  the  great  vessels  from  the  base  of  the  skull  down  to  the 
supraclavicular  fossa.  They  may  be  divided  into  an  upper  and  lower  set. 
The  upper  glands  are  always  represented  by  one  or  more  nodes  lying  in  the 
bifurcation  of  the  common  carotid  artery.  They  receive  lymph  from  the  palate, 
the  nasal  fossa',  the  pharynx,  the  larynx,  the  tongue,  and  the  tonsils.  The 
more  posterior  glands  receive  lymph  from  the  interior  of  the  cranium,  the  deep 
muscles  of  the  neck,  and  the  lowest  portion  of  the  pharynx.  The  lower  set  of 
glands  lie  along  the  lower  portion  of  the  great  vessels  and  in  the  supraclavicular 
fossa  upon  the  scaleni  muscles  and  along  the  cords  of  the  brachial  plexus.  They 
receive  lymph  from  the  superior  chains  and  from  the  neighboring  skin  and 


INFLAMMATORY   PROCESSES    OF   THE   NECK 


547 


muscles,  also  from  the  trachea,  lower  portion  of  the  larynx,  the  esophagus,  and 
the  thyroid  gland.  They  communicate  with  the  lymphatics  of  the  axilla  and 
thoracic  Avails. 

The  lymphatic  vessels  after  leaving  the  lower  chain  unite  into  a  large  trunk, 
which  empties  into  the  thoracic  duct  on  the  left  side.  On  the  right  side,  into 
the  lymphatic  ductus  communis,  or  directly  into  the  venous  circulation  at  the 
junction  of  the  subclavian  and  internal  jugular  veins.  The  suboccipital  glands 
lie  upon  the  origin  of  the  trapezius  muscle  and  receive  lymph  from  the  occipital 
muscle  and  back  of  the  head.  There  is  usually  one  gland  over  the  origin  of 
the  sterno-mastoid  muscle.  This  receives  lymph  from  the  posterior  part  of  the 
external  ear  and  neighboring  portion  of  the  scalp,  and  empties  into  the  super- 
ficial chain  of  lymphatics  in  the  neck. 

Acute  Suppurative  Processes  of  the  Neck.— The  acute  suppurative  processes 
of  the  neck  occur  most  commonly  during  childhood,  adolescence,  and  early 
adult  life — caries  of  the  teeth,  infections  processes  in  the  mouth,  the  jaws, 
and  the  integument  of  the  head  and  face  being  more  frequent  during  the  first 
thirty  years  of  life  than  later.  While 
these  suppurative  processes  show  every 
possible  variation  in  intensity,  they  are, 
in  the  majority  of  cases,  localized  rather 
than  spreading  infections,  and  common- 
ly end  in  the  formation  of  an  abscess 
rather  than  in  a  spreading  phlegmonous 
process.  They  affect,  in  a  large  pro- 
portion of  cases,  the  submaxillary  re- 
gion; further,  the  loose  connective-tis- 
sue planes  already  indicated.  Many 
of  these  abscesses  arise  from  lymph 
nodes,  either  superficial  or  deep,  as  the 
result  of  infection  of  the  lymph  chan- 
nels leading  to  the  gland,  from  the  most 
varied  causes.  In  children  especially, 
from  infection  through  carious  teeth 
and  suppurative  periostitis  of  the  jaw, 
frequently  from  infection  of  the  mucous 
membrane  of  the  mouth  and  the  tonsils. 
As  secondary  infections  in  the  course  of 
acute  infectious  diseases — the  exanthe- 
mata, typhoid,  diphtheria,  etc.  Further, 
as  the  result  of  infection  of  the  salivary 
glands  under  similar  conditions;  also  as  the  result  of  cutaneous  infections 
following  eczema  of  the  face  and  scalp,  fnrnnculosis,  and  pediculosis  capitis. 

We  have  already  indicated  the  course  and  symptoms  of  abscess   and   of 
phlegmonous  inflammation  in  the  submaxillary  region  under  Diseases  of  the 


Fig.  192. —  Acute  Abscess  in  the  Submax- 
illary Region.     (Author's  collection.) 


548  THE   NECK 

Salivary  Glands.  Here  it  may  be  added  that  in  the  majority  of  cases  the 
process  lies  outside  the  inclosing  fibrous  envelope  of  the  submaxillary  gland 
itself,  and  runs  its  course  as  an  acute  abscess,  giving  perfectly  plain  indications 
of  its  character  without  grave  constitutional  disturbance,  and  finally  breaking 
through  the  skin  if  not  incised.  If  the  infection  is  confined  within  the  fibrous 
envelope  of  the  gland,  the  signs  and  symptoms  of  a  grave  constitutional  and 
local  infection  are  much  more  marked.  The  process  often  takes  on  a  sloughing 
and  gangrenous  character.  The  submaxillary  gland  itself  usually  remains 
intact,  the  purulent  or  necrotic  inflammation  being  confined  to  the  surrounding 
connective  tissues.  The  mucous  membrane  of  the  mouth,  pharynx,  and  larynx 
are  often  infiltrated  and  edematous.  Inability  to  open  the  mouth,  difficulty  in 
swallowing,  speaking,  and  severe  dyspnea  may  be  present.  The  head  is  held 
rigidly  bent  toward  the  affected  side.  Salivation  and  a  fetid  odor  of  the  breath 
are  marked.  In  untreated  cases  death  may  occur  in  a  few*  days  from  septic 
poisoning.  (With  all  the  attending  symptoms  characterizing  this  condition, 
see  Septicemia.)  The  Streptococcus,  or  Staphylococcus  pyogenes  aureus,  or  both, 
or  one  or  other  of  these  with  the  Pneumococcus  or  Bacillus  coli,  may  be  found 
in  cultures  from  the  pus.  Increase  in  the  large  polynuclear  leucocytes  is  espe- 
cially marked.  In  some  cases  death  may  occur  from  asphyxia  due  to  edema 
of  the  glottis.  The  local  signs  are  easily  distinguished,  the  whole  upper  part 
of  the  neck  on  one  side  is  hard,  tender,  painful,  and  greatly  swollen.  The 
tongue  is  forced  upward  against  the  roof  of  the  mouth.  The  skin  may  be 
normal  in  color  early  in  the  disease ;  later  it  becomes  red,  or  deep  mahogany-red 
as  the  infection  approaches  the  skin  surface. 

Abscesses  at  the  Angle  of  the  Jaw. — Abscesses  at  the  angle  of  the  jaw 
occasionally  occur  from  infectious  processes  connected  with  the  posterior  molar 
teeth.  The  most  notable  symptom,  other  than  that  of  an  acute  abscess,  con- 
sists of  inability  to  open  the  mouth. 

Abscesses  of  the  Submental  Lymph  Nodes. — Abscesses  of  the  submen- 
tal lymph  nodes  may  occur  from  infection  of  the  lips,  the  chin,  the  floor  of 
the  mouth,  and  front  of  the  tongue.  The  resulting  abscess  forms  a  tender,  red, 
prominent,  sometimes  fluctuating,  swelling  under  the  chin,  and  remains  local- 
ized without  tending  to  spread  widely. 

Abscesses  Arising  in  the  Deep  Lymph  Nodes  of  the  Neck.-^- Abscesses 
arising  in  the  deep  lymph  nodes,  notably  in  the  glands  of  the  upper  set  which 
lie  near  the  bifurcation  of  the  carotid,  are  less  common  than  those  in  the  sub- 
maxillary region.  They  occur  from  similar  kinds  of  infection,  during  con- 
valescence from  the  exanthemata,  especially  scarlet  fever,  from  carious  teeth, 
mastoiditis,  inflammation  of  the  middle  ear,  infectious  processes  of  the  nose, 
ozena,  stomatitis,  etc. 

The  infection  is  characterized  by  general  symptoms  of  sepsis  and  by  the 
formation  of  a  brawny,  hard,  tender,  painful  swelling,  which  lies  beneath 
the  sterno-mastoid  and  raises  that  muscle  from  its  normal  position.  The  head 
is  inclined  toward  the  affected  side.     The  inflammatory  infiltration  often  ex- 


INFLAMMATORY  PROCESSES  OF  THE  NECK        5-19 

tends  to  the  interior  of  the  mouth  and  pharynx,  and  produces  the  symptoms 
already  described.  The  process  may  end  in  resolution;  usually,  an  abscess 
forms  which  may  point  at  the  anterior  or  posterior  border  of  the  stemo-mastoid, 
or  perforate  the  deep  fascia  and  spread  up  and  down  the  neck  beneath  the 
platysma.  In  some  cases  the  pus  travels  down  in  the  sheath  of  the  vessels 
and  into  the  axilla,  in  others  downward  into  the  mediastinum  with  the  pro- 
duction of  fatal  suppuration,  or  septic  pleuritis,  or  pericarditis,  or  pyemia,  and 
death  from  general  sepsis.  Occasionally  such  an  abscess  may  rupture  into  the 
pharynx,  or  more  rarely  into  the  trachea.  One  of  the  less  common  results  of 
these  abscesses  is  ulceration  and  perforation  of  the  walls  of  the  blood-vessels 
with  fatal  hemorrhage ;  any  one  of  the  important  arteries  of  the  neck  may  be 
opened  in  this  way.  If  the  abscess  is  already  open  outwardly,  the  bleeding  is 
external.  If  not,  then  internal  into  the  abscess  cavity,  into  the  mediasti- 
num, pleura,  pericardium,  etc.  When  the  septic  process  involves  the  wall 
of  a  vein,  septic  thrombosis  of  the  vein  results,  with  its  attendant  danger  of 
pyemia. 

In  operating  upon  these  cases  it  is  the  duty  of  the  surgeon,  when  the  char- 
acter of  the  infection  is  severe  and  shows  a  distinctly  progressive  tendency,  to 
make  such  incisions  as  will  render  any  further  burrowing  and  extension  of 
the  pro-cess  from  retention  of  pus,  or  from  the  existence  of  a  dependent  pocket, 
or  from  imperfect  relief  of  tension  absolutely  impossible.  To  illustrate  what 
I  mean,  I  may  say  that  in  bad  cases  of  this  sort  I  have  sometimes  made  a 
curved  incision,  convex  downward,  beginning  near  the  middle  line,  beneath 
the  chin  and  crossing  the  level  of  the  hyoid  bone  to  end  beneath  the  ear,  and 
joined  it  near  its  middle  by  an  incision  extending  downward,  parallel  to  the 
sterno-mastoid  muscle,  ending  at  the  clavicle ;  the  infiltrated  area  was  thus 
opened  throughout  its  entire  length,  and  all  danger  of  pocketing  and  tension 
was  relieved.  The  resulting  scars  have  not  been  disfiguring,  and  the  operation 
has  been  followed  by  immediate  relief  of  threatening  symptoms.  When  the 
pus  burrows  into  the  axilla,  local  pain,  swelling,  and  edema,  pain  on  raising 
the  arm,  etc.,  will  be  present.  Sometimes  fluctuation  may  be  detected  above 
and  below  the  clavicle.  But  in  the  diagnosis  of  all  these  deep-seated  purulent 
processes,  the  local  signs  are  usually  those  of  a  boardlike,  dense  infiltration. 
Fluctuation  is  usually  a  sign  developed  later,  if  at  all,  and  one  for  which  no 
good  surgeon  waits  before  making  suitable  incisions. 

Abscesses  in  the  Supraclavicular  Region, — Abscesses  in  the  supraclavi- 
cular region  may  originate  in  the  lymph  nodes  of  that  region,  or  develop  as 
an  extension  of  the  processes  just  described.  They  may  break  through  the 
deeper  fascial  planes  and  appear  as  fluctuating  abscesses  beneath  the  platysma, 
or  burrow  in  one  or  other  of  the  directions  already  indicated.  It  is  to  be 
remembered  that  an  early  diagnosis  and  appropriate  treatment  in  all  these 
cases  is  of  the  utmost  importance,  since,  in  many  instances,  the  inflammatory 
process  is  distinctly  circumscribed  and,  if  opened  early,  will  remain  so.  If, 
on  the  other  hand,  temporizing  measures  are  used,  the  dangers  of  a  spreading 


550  THE   NECK 

septic  process  are  very  great.  In  the  absence  of  fluctuation,  a  point  of  extreme 
local  tenderness  in  the  hard  and  swollen  area,  a  center  of  intense  redness  'which 
shades  off  into  the  surrounding  skin,  a  localized  doughy  condition  in  the 
center  of  a  hard  infiltrated  mass,  are  good  guides  for  the  knife. 

Retropharyngeal  Abscess. — Suppuration  in  the  retrovisceral  space,  be- 
tween the  pharynx  or  esophagus  and  the  anterior  surface  of  the  bodies  of  the 
vertebrae,  accurs  as  an  acute  process  less  commonly  than  in  the  other  spaces. 
It  is  more  common  among  infants  and  children  than  among  adults.  The 
infection  occurs  as  the  result  of  wounds  of  the  pharynx  and  esophagus,  from 
ulceration  caused  by  the  pressure  of  a  foreign  body,  as  a  complication  of  the 
exanthemata,  notably  scarlet  fever  in  young  infants  between  one  and  three 
years  old.  Such  an  abscess  may  also  follow  diphtheria,  erysipelas,  or  any 
ulcerative  process  of  the  throat.  The  infection  may  take  place  through  the 
lymphatics  of  the  pharynx  or  of  the  nasal  fossse.  Very  often  the  process 
originates  in  the  lymph  nodes  at  the  level  of  the  second  or  third  cervical  ver- 
tebra. The  pus  collects  between  the  posterior  wall  of  the  pharynx  and  the 
spinal  column,  and  may  spread  downward  into  the  posterior  mediastinum,  more 
rarely  into  the  sheath  of  the  great  vessels,  occasionally,  thence,  into  the  axilla 
or  toward  the  surface  either  in  front  of  or  behind  the  sterno-mastoid.  Still 
more  rarely  in  the  parotid  region. 

The  signs  and  symptoms  of  acute  retropharyngeal  abscess  are,  in  addition 
to  the  constitutional  symptoms  of  sepsis,  due  largely  to  the  mechanical  inter- 
ference with  swallowing  and  breathing  caused  by  the  bulging  forward  of  the 
posterior  pharyngeal  wall.  There  is  pain  in  the  back  of  the  throat.  If  the 
abscess  is  high  up  in  the  pharynx,  the  patient  breathes  through  the  opened 
mouth  on  account  of  the  closure  of  the  posterior  nares  by  the  pharyngeal 
tumor.  During  sleep,  if  the  mouth  closes,  an  attack  threatening  death  from 
asphyxia  may  occur.  There  is  increasing  difficulty,  and  finally  inability  to 
swallow.  Speech  is  interfered  with,  the  voice  is  thick  and  of  a  nasal  quality. 
There  is  gradually  increasing  dyspnea.  The  head  is  held  immovable  and  a 
little  extended.  External  inspection  and  palpation  may  reveal  tenderness, 
swelling,  and  infiltration  on  one  or  both  sides  of  the  neck  behind  the  angle 
of  the  jaw,  or  in  the  submaxillary  region,  or  lower  down.  In  adults  inspection 
of  the  throat  will  show  a  bulging  of  the  mucous  membrane  of  the  pharynx, 
either  median  or  more  marked  on  one  side,  the  mucous  membrane  may  be 
smooth,  shining,  and  red,  or  red  and  edematous,  or  normal  in  appearance. 
Inspection  through  the  mouth  is  difficult  or  impossible  in  infants,  and  the  most 
important  diagnostic  signs  are  to  be  recognized  by  palpation  of  the  pharynx 
with  the  forefinger  introduced  into  the  mouth.  The  bulging  of  the  posterior 
pharyngeal  wall  forward  is  thus  easily  detected,  and  usually  fluctuation  as  well. 
If  these  abscesses  burst  into  the  pharynx  death  may  occur  from  aspiration  of 
pus  into  the  trachea  and  asphyxia,  or  later  on  from  septic  pneumonia.  If  the 
abscess  approaches  the  skin  surface  it  will  give  corresponding  signs — i.  e.,  infil- 
tration, induration,  tenderness,  sometimes  redness  of  the  skin  and  fluctuation. 


INFLAMMATORY   PEOCESSES    OF   THE   NECK  551 

Infection  of  the  mediastinum  will  produce  the  symptoms  of  fatal  sepsis,  or 
purulent  pleuritis,  or  pericarditis,  as  the  case  may  be. 

Chronic  Abscesses  of  the  Retropharyngeal  Space. — Chronic  abscesses  of 
the  retropharyngeal  space  are,  for  the  most  part,  due  to  tubercular  caries  of 
the  bodies  of  the  cervical  vertebrae.  They  will  be  discussed  under  the  diseases 
of  the  spine. 

Chronic  Inflammations  of  the  Neck. — Chronic  inflammations  of  the  neck 
are  most  often  caused  by  tuberculosis  and  other  chronic  inflammations  of  the 
cervical  lymph  nodes,  by  syphilis,  and  actinomycosis.  Certain  other  affections 
will  also  be  considered. 

Actinomycosis.      (See  Actinomycosis.) 

Inflammatory  Hyperplasia  of  the  Cervical  Lymph  Nodes. — During  the  early 
years  of  life  up  to  the  tenth  year,  catarrhal  inflammations  of  the  mucous  mem- 
brane of  the  nose  and  throat,  tonsillitis,  caries  of  the  teeth,  furuncles  and  small 
abscesses  of  the  face,  inflammations  of  the  ear,  the  acute  exanthemata,  irrita- 
tions and  infections  of  the  skin,  and  of  the  face  and  scalp  are  exceedingly  fre- 
quent. After  this  age  their  frequency  gradually  diminishes  until  adult  life, 
when  they  are  notably  less  common  than  during  childhood.  As  the  result  of  these 
external  irritations  there  occur  infections  of  the  cervical  lymph  nodes  of  various 
kinds  and  degrees.  In  many  instances  the  infection  is  caused  by  pus  microbes  in 
sufficient  number  and  virulence  to  produce  suppuration  of  the  gland  tissue  and 
a  localized  abscess,  as  already  described.  In  other  instances  the  process  stops 
short  of  suppuration,  the  tenderness  of  the  gland  disappears,  but  the  gland 
remains  enlarged  for  some  time,  or  even  permanently.  In  still  other  cases  no 
acute  inflammation  precedes ;  in  the  presence  of  some  chronic  source  of  irrita- 
tion one  or  more  lymph  nodes  become  painlessly  and  chronically  enlarged.  In 
any  of  these  cases,  a  removal  of  the  source  of  irritation  or  infection  may  be 
followed  by  a  gradual  diminution  in  the  size  of  the  gland  until  it  regains  its 
normal  size.  This  condition  of  the  lymph  nodes  is  known  as  inflammatory 
hyperplasia,  and  such  glands  possess  the  following  characters :  They  vary  in 
size  from  that  of  a  pea  to  a  hazelnut ;  they  are  of  moderately  firm  consistence, 
neither  very  hard  nor  very  soft ;  they  are  neither  tender  nor  painful ;  they  are 
freely  movable ;  they  do  not  tend  to  increase  in  size  nor  to  undergo  degenera- 
tive changes  of  any  sort.  They  give  rise  to  no  symptoms,  except  possibly 
deformity,  and  would  be  of  no  particular  surgical  interest  were  it  not  for 
the  fact  that  it  is  not  always  easy  to  distinguish  them  from  lymph  glands  the 
seat  of  tuberculosis  before  the  latter  have  undergone  degenerative  changes.  If, 
in  the  presence  of  some  local  source  of  irritation — a  carious  tooth,  pediculosis 
capitis,  hypertrophied  tonsils,  an  eczema  of  the  nose  or  the  ear,  etc. — we  find 
one  or  more  lymph  nodes  enlarged  in  a  child's  neck  without  local  pain  or  ten- 
derness, we  must  try  to  distinguish  between  these  two  conditions — simple  in- 
flammatory hyperplasia  and  tuberculosis.  If  we  remove  the  local  source  of 
irritation  and  the  gland  grows  smaller,  or  disappears,  or  remains  entirely 
quiescent  for  some  time,  it  is  probably  not  tuberculosis.     If  it  grows  larger, 


552 


THE   NECK 


or  if  other  glands  become  enlarged,  or  if  the  gland  softens  or  becomes  adherent 
to  the  surrounding  structures,  it  is  usually  due  to  tuberculosis.  In  case  of 
doubt,  it  is  far  better  to  remove  one  or  more  glands  for  inspection  and  micro- 
scopic examination  and  settle  the  diagnosis  once  and  for  all,  so  that  the  glands, 
if  tubercular,  may  be  promptly  removed. 

Tuberculosis  of  the  Lymph  Glands  of  the  Neck. — Tuberculosis  of  the  lymph 
nodes  is  one  of  the  most  frequent  forms  of  tubercular  disease,  and  the  lymph 
nodes  of  the  neck  are  the  seat  of  the  process  in  about  ninety  per  cent  of  lym- 
phatic tubercular  infections.  The  disease  is  most  frequent  between  the  fifteenth 
and  thirtieth  years  of  life,  but  may  occur  at  any  age.  An  hereditary  tendency 
to  tubercular  infection  is  present  in  a  considerable  proportion  of  cases.  Bad 
hygienic  surroundings,  improper  food,  overcrowding,  overwork,  etc.,  cause  the 
disease  to  be  much  more  frequent  among  the  poor  than  among  the  well-to-do. 
A  considerable  proportion  of  those  who  suffer  from  tubercular  glands  of  the 
neck  die  of  pulmonary  phthisis,  or  from  acute  general  miliary  tuberculosis. 
Infection  takes  place  through  the  mucous  membrane  of  the  throat,  mouth,  and 

nose,  or  through  the  integument  of 
the  face  and  neck.  A  less  common 
avenue  is  through  the  mucous  mem- 
brane of  the  bronchi,  causing  tu- 
berculosis of  the  bronchial  glands 
and  an  ascending  infection  to  the 
cervical  lymph  nodes.  Usually  the 
infection  advances  downward  from 
the  upper  to  the  lower  cervical 
glands.  Carious  teeth  and  the  ton- 
sils are  thought  to  be  the  two  most 
common  avenues  for  the  entrance 
of  tubercle  bacillus  in  these  cases. 
Hypertrophied  tonsils  are  known 
to  be  the  home  of  the  tubercle  ba- 
cillus in  many  instances.  Trifling 
lesions  of  the  skin  and  mucous 
membrane  of  all  kinds  afford  an 
avenue  of  entrance  for  the  bacilli, 
whence  they  reach  the  lymph  nodes, 
and  under  favorable  local  and  gen- 
eral conditions  are  enabled  to  grow 
and  thrive.  The  acute  infectious 
diseases  of  childhood — typhoid,  etc. 
— all  predispose  to  the  occurrence  of  tubercular  infections.  Primary  tuber- 
cular ulcerations  of  the  skin  or  mucous  membrane  may  be  followed  by  tubercu- 
lar infection  of  lymph  nodes,  but  such  an  occurrence  is  rare  in  comparison 
with  the  number  of  cases  in  which  the  bacillus  leaves  no  trace  at  its  point 


Fig.  193.  —  Tuberculous  Lymph  Nodes  of  the 
Neck,  Showing  Periglandular  Infiltration. 
(New  York  Hospital,  service  of  Dr.  Murray.) 


INFLAMMATORY    PROCESSES    OF    THE    NECK 


553 


of  entry,  but  first  makes  its  presence  evident  in  the  lymph  nodes.  The  disease 
may  affect  one  gland  or  one  group  of  glands,  or  several  groups  on  the  same 
side,  or  on  both  sides  of  the  neck.  The  infection  may  slowly  travel  from  one 
gland  to  another  until  many  are  involved,  or  an  entire  group  may  be  infected 
at  once.  Clinically  the  disease  pre- 
sents itself  in  a  number  of  types; 
the  characters  of  each  are,  how- 
ever, often  combined  in  the  same 
case.  We  may  distinguish  (I)  cases 
in  which  the  infection  remains  con- 
fined to  the  gland  tissue  proper; 
(II)  cases  in  which  the  infection 
extends  to  the  periglandular  tissues. 
Class  I.  Cases  in  which  the 
Infection  Remains  Confined  to  the 
Gland  Tissue  Proper. — In  some 
cases  the  infection  is  confined  to  a 
single  gland,  or  to  a  small  group  of 
glands,  and  the  clinical  picture  will 
vary  according  to  the  activity  of  the 
tubercular  process.  The  glands  in 
the  upper  part  of  the  neck  are  often 
the  seat  of  the  disease ;  the  submax- 
illary region  at  the  angle  of  the  jaw, 
under  the  chin,  in  front  of  the  ear, 
in  the  parotid  gland,  or  in  the  su- 
praclavicular fossa.  The  tumor  is 
rounded  or  ovoid,  painless  and  in- 
sensitive, moderately  firm,  movable,  and  may  be  as  large  as  a  hazelnut,  seldom 
larger  than  a  walnut;  careful  examination  will  often  detect  other  smaller  glands 
in  the  same  region.  It  may  be  stated  here,  as  a  matter  of  general  experience, 
that  upon  operation,  the  number  of  glands  involved  will  almost  always  be 
found  more  numerous  and  their  distribution  more  extensive  than  could  be 
determined  by  external  palpation.  The  superficial  glands  alone  are  felt.  At 
the  operation  many  glands  are  found  to  be  involved.  The  surgeon,  therefore, 
plans  his  incisions  accordingly,  and  makes  his  cut  in  such  a  direction  that  it 
can  be  freely  enlarged  should  occasion  require.  Infection  of  an  entire  group 
of  glands  is  much  more  common  than  that  of  a  single  gland.  A  conglomerate 
mass  of  enlarged  glands  can  then  be  distinguished  movable  on  the  surrounding 
parts,  and  of  variable  size  and  shape,  of  hard  or  soft  consistence,  occupying 
some  part  of  the  neck.  The  individual  glands  can  often  be  distinguished.  In 
other,  and  not  uncommon,  cases  several  groups  of  glands  on  one  or  both  sides 
of  the  neck  will  form  masses  or  chains  of  glands,  often  of  considerable  size, 
causing  marked  deformities. 


Fig.  194 — Tuberculous  Lymph  Nodes,  Deep  Cer- 
vical, Chatn  beneath  the  Sternomastoid  Mus- 
cle.    (Author's  collection.) 


554 


THE   NECK 


The  history  is  of  the  slow,  or  rather  rapid,  or  intermittent  increase  in  size 
in  one  set  of  glands  after  another,  extending  over  months  or  years.  The  glands 
are  painless  and  insensitive.  Pressure  symptoms  are  usually  wanting.  In  the 
majority  of  cases  the  general  health  is  not  seriously  interfered  with;  the 
patients  may  appear  to  be  in  fair  general  health  or,  on  the  other  hand, 
they  may  be  more  or  less  anemic.  If  pulmonary  phthisis  or  other  tuber- 
cular lesion  coexists,  it  will  produce  its  own  symptoms.  There  is,  however, 
a  certain  set  of  cases  where  many  glands  are  successively  involved,  and  usu- 
ally, also,  glands  in  other  regions  than  the  neck — the  axilla?,  groins,  retro- 
peritoneal glands,  -  etc. — in 
which  the  patients  have 
from  time  to  time  attacks 
of  high  fever,  lasting  for 
days  or  weeks.  These  are 
the  cases  in  which  the  course 
of  the  condition  is  that  of 
Hodgkin's  disease,  with  a 
fatal  issue,  as  already  de- 
scribed. 

Differential  Diagnosis. 
- — Tuberculous  glands  of 
the  neck,  however  extensive, 
may  be  differentiated  from 
leukemia  by  an  examina- 
tion of  the  blood;  from  pri- 
mary sarcoma  of  the  lymph 
glands  by  bacteriological 
examination  of  the  excised 
glands,  and  inoculation  of 
susceptible  animals.  The 
pathological  lesions  found 
in  these  generalized  tuber- 
culous lymph  nodes  vary  much  in  different  cases.  There  may  be  distin- 
guished : 

.A.  A  purely  hyperplastic  form,  most  common  in  the  cases  running  the 
course  of  an  acute  fatal  pseudoleukemia.  The  glands  are  enlarged  and  of 
moderately  firm  consistence ;  on  section  they  appear  as  a  simple  increase  of 
gland  tissue,  and  show  neither  tubercles  nor  caseation.  Under  the  microscope 
evidence  of  tuberculosis  is  usually  wanting,  although  in  some  cases  tubercle 
bacilli  may  be  found  in  small  numbers.  Inoculation  of  animals  with  the  glan- 
dular substance  is  usually  necessary  to  establish  the  diagnosis.  These  rapidly 
growing  hyperplastic  lymph  nodes  differ  in  no  way  under  the  microscope  from 
primary  lymphosarcoma,  and  it  must  be  confessed  that  at  present  the  pathology 
of  these  conditions  is  still  obscure. 


Fig.  195. — Tuberculosis  of  the  Lymph  Nodes  of  the  Neck, 
Periglandular  Infiltration  and  Diffuse  Abscess  In- 
volving the  Deep  Connective-Tissue  Planes  of  the 
Neck.     (New  York  Hospital,  service  of  Dr.  F.  W.  Murray.) 


INFLAMMATORY   PROCESSES    OF   THE   NECK  555 

B.  Hyperplastic  inflammation  of  the  glands  with  the  formation  of  larger 
or  smaller  tubercles.  The  glands  are  enlarged  or  normal  in  size.  Upon  the 
grayish-red,  cut  surface,  larger  or  smaller  grayish  dots  or  areas  can  be  dis- 
tinguished, sometimes  occupying  a  considerable  part  of  the  gland.  Under  the 
microscope  they  are  recognizable  as  tubercles  and  areas  of  tubercular  granu- 
lation tissue.     Bacilli  are  few  in  number. 

C.  Caseation.  Degenerative  changes  take  place  in  the  tubercle  tissue,  and 
produce  caseous  areas  in  the  gland.  These  may  be  large  or  small,  of  pinhead 
size,  or  may  occupy  the  entire  gland ;  of  firm,  soft,  and  crumbly,  or  fluid  con- 
sistence. Such  caseous  areas  may,  after  a  time,  undergo  calcification.  The 
color  of  the  caseous  areas  is  yellow,  yellowish-white,  or  white.  If  fluid,  the 
microscopic  appearances  will  be  that  of  a  liquid  containing  abundant  fat  drops, 
fatty  and  granular  degenerated  cells,  and  granular  detritus.  Tubercle  bacilli 
are  few  in  number.     Inoculation  of  susceptible  animals  produces  tuberculosis. 

Class  II.  Cases  in  which  the  Infection  Extends  to  the  Periglandular 
Tissues. — In  these  cases  the  capsule  of  the  gland  is  at  first  thickened,  and  later 
forms  adhesions  to  the  surrounding  structures  of  whatever  kind.  Sooner  or 
later  perforation  of  the  capsule  takes  place,  and  the  broken-down  tuberculous 
material  is  poured  into  the  surrounding  tissues.  Thus  diffuse  tuberculous 
inflammations  may  occur  in  the  connective-tissue  planes,  or,  what  is  more 
common,  the  infection  advances  toward  the  surface  with  the  formation  of  a 
tuberculous  abscess.  The  skin  at  first  becomes  adherent,  then  infiltrated,  livid 
in  color,  thinned,  and  finally  ruptures,  giving  escape  to  tuberculous  cheesy 
material  and  fluid  resembling  pus  in  appearance.  There  is  left  behind  a  cavity 
lined  by  velvety  tubercular  granulation  tissue  or  caseous  material.  The  skin 
edges  of  the  opening  are  thinned  out  and  undermined,  red  or  blue  in  color. 
Such  an  orifice  may  increase  in  size  by  ulceration,  and  remain  open  indefinitely, 
or  gradually  heal  down  to  a  tuberculous  sinus,  or  after  a  time  heal  entirely, 
leaving  behind  a  depressed,  puckered  scar,  often  with  radiating  bars  of  cica- 
tricial tissue  around  its  circumference.  In  many  cases,  after  the  skin  is  per- 
forated, pale  fungating  granulations  sprout  from  the  edges  of  the  orifice,  pro- 
ducing the  characteristic  appearances  of  a  tuberculous  sinus. 

Infection  of  the  periglandular  tissues  with  pyogenic  microbes  is  not  an  un- 
common accident  either  before  or  after  perforation  of  the  skin.  If  the  infection 
takes  place  before  the  skin  is  involved,  the  course  of  the  infection  is  that  of 
an  acute  abscess  of  the  neck,  and  the  diagnosis  may  only  be  made  when,  upon 
incising  the  abscess,  caseous  masses  escape.  Such  infection  may  be  curative ; 
the  tuberculous  focus  may  be  entirely  cut  off  from  the  surrounding  tissues  and 
appear  as  an  entire  gland,  or  as  caseous  material  in  the  discharge  from  the 
abscess,  to  be  followed  by  complete  healing  of  the  cavity.  In  other  cases  the 
pus  infection  renders  the  condition  worse;  the  acute  abscess,  after  incision, 
leaves  behind  a  tuberculous  cavity.  As  the  result  of  the  periglandular  infil- 
tration, the  glands  become  matted  together  with  firm,  fibrous  tissue,  and  these, 
with  the  infiltrated  surrounding  tissues,  form  firm,  immovable,  hard  tumors, 


556  THE   NECK 

sometimes  of  large  size.  In  unfavorable  cases  all  the  stages  of  the  disease  may 
he  found  present  in  the  same  case — isolated  glands,  glandular  conglomerates, 
abscesses,  sinuses,  tubercular  ulcerations,  scars,  and  areas  of  pus  infection. 
When  the  glands  soften  and  the  rupture  takes  place  into  the  deeper  tissues, 
the  infection  may  travel  downward  in  the  connective-tissue  planes  and  come 
to  the  surface  as  a  cold  abscess  above  the  clavicle,  on  the  chest  wall,  or  in  the 
axilla. 

It  is  only  in  rare  cases  that  symptoms  of  compression  of  the  trachea,  esoph- 
agus, or  of  nerve  trunks,  with  the  production  of  neuralgias,  attends  tubercular 
glands  of  the  neck,  even  though  the  masses  are  of  large  size.  As  a  general  rule, 
the  diagnosis  of  tuberculous  glands  of  the  neck  is  easy.  Simple  inflammatory 
hyperplasia,  as  already  indicated,  is  not  of  a  progressive  character.  Malignant 
lymphoma  tends  to  grow  steadily  larger;  the  individual  glands  are  of  larger 
size ;  periadenitis  and  abscesses  are  wanting ;  glands  in  other  regions  are  usually 
soon  involved.  From  cystic  tumors,  tubercular  lymphoma  can  be  differentiated 
by  the  use  of  an  aspirating  needle.  In  all  cases  of  doubt  the  removal  of  a  gland 
will  usually  aid  in  the  diagnosis. 

Syphilis  of  the  Cervical  Lymph  Glands. — Syphilis  of  the  cervical  lymph 
glands  may  occur  in  all  the  stages  of  the  disease.  Since  chancre  is  most  com- 
mon on  the  lips,  tongue,  tonsils,  and  face  rather  than  on  the  skin  of  the  neck, 
the  glands  in  the  upper  part  of  the  neck — submental  and  submaxillary — are 
usually  involved.  They  coexist  with  the  chancre,  and  are  usually  remarkably 
large  and  hard.  In  secondary  syphilis  the  glands  of  the  neck  are  uniformly 
enlarged.  The  superficial  glands  along  the  sterno-mastoid,  at  the  base  of  the 
mastoid  process  and  at  the  insertion  of  the  trapezius,  are  usually  palpable. 
The  glands  are  hard  and  insensitive,  movable,  and  vary  in  size  from  a  pea  to 
an  almond.  Other  signs  of  syphilis  are  present.  Quite  rarely  a  gumma  may 
form  in  the  submaxillary  region  as  a  slowly  growing,  movable,  painless  tumor, 
which  finally  softens  and  ulcerates.  The  early  diagnosis  is  often  difficult,  and 
depends  largely  upon  the  effects  of  iodid.  I  have  recently  seen  a  gumma  be- 
neath the  sterno-mastoid  which  closely  resembled  a  broken-down  tubercular 
lymph  node. 

Under  the  title  Hodghin's  Disease  we  have  already  discussed  the  diagnosis 
of  malignant  lymphoma  or  'pseudoleukemia. 

Primary  Sarcoma  of  the  Lymph  Glands — Lympho-sarcoma. — There  remains  to 
be  considered  under  primary  affections  of  the  lymph  glands  primary  sarcoma 
of  the  lymph  glands — lympho-sarcoma.  The  new  growth  begins  in  a  lymph 
gland ;  the  gland  increases  in  size,  and  forms  at  first  a  soft,  movable,  rounded 
or  oval  tumor.  On  section  it  may  differ  in  no  particular  from  an  ordinary 
hyperplastic  lymph  node.  Microscopically  the  picture  is  that  of  a  round-celled 
sarcoma,  usually  with  a  fine  intercellular  reticulum.  In  other  cases  combina- 
tions occur  with  spindle  cells  or  other  forms  of  sarcoma  cells.  Clinically  the 
growth  is  characterized  by  a  rather  early  perforation  of  the  capsule  and  infil- 
tration of  the  surrounding  structures;  a  large  tumor  is  rapidly  formed,  which 


INFLAMMATORY   PROCESSES    OF   THE   NECK 


557 


causes  increasing  pressure  symptoms  upon  blood-vessels,  nerves,  esophagus, 
pharynx,  and  trachea.  The  skin  is  involved  after  a  time;  ulceration,  the  for- 
mation of  fungoid  growths,  hemorrhage,  infection,  and  sloughing  of  the  tumor 
tissue  are  among  the  events  of  the  later  stages  of  the  disease.  The  other  lymph 
nodes  usually  remain  unaffected,  but  secondary  tumors  often  form  in  the  vicin- 
ity, and  may  become  fused  with  the  parent  tumor.  The  disease  is  rapidly 
fatal ;  life  is  rarely  prolonged  for  more  than  a  year  or  two  from  the  appear- 
ance of  the  tumor.  Death  occurs  from  pressure  on  the  trachea  and  esophagus, 
from  hemorrhage,  from  inva- 
sion of  the  internal  jugular  with 
fatal  thrombosis.  Metastases 
may  form  in  the  lungs,  etc.,  if 
the  patient  survives  for  a  suffi- 
cient time. 

Secondary  Carcinomatous  In- 
fection of  the  Lymph  Nodes  of 
the  Neck. — As  already  noted  in 
many  places  in  this  book,  sec- 
ondary glandular  tumors  occur 
in  the  neck  in  cases  of  carci- 
noma of  the  lips,  tongue,  face, 
salivary  glands,  larynx,  thyroid 
gland,  esophagus,  mammary 
gland,  etc.,  the  situation  of  the 
secondary  glandular  tumors  de- 
pending upon  the  seat  of  the 
primary  growth  and  the  direc- 
tion of  the  lymphatic  current, 
less  often  in  cases  of  sarcoma. 
The  carcinomatous  glands  form 
hard,  nodular  masses,  which 
soon  become  adherent  to  the 
surrounding  parts.  They  often 
undergo  degenerative  changes, 
may  soften,  break  down,  and 
perforate  the  skin,  forming  ul- 
cerating or  fungating  tumors.  It  is  usually  possible  to  find  the  primary  tumor 
or  the  scar  left  by  its  removal.  I  recall  but  one  case  in  which  this  was  not 
the  case.  A  man  of  thirty-five  came  to  me  with  numerous  discrete  glandular 
tumors  on  both  sides  of  his  neck,  affecting  chiefly  the  groups  of  glands  along 
the  sheath  of  the  vessels.  One  gland  was  removed,  and  was  reported  to  be  a 
typical  carcinoma.  No  primary  growth  could  be  found,  and  since  the  patient 
withdrew  himself  from  observation,  I  never  knew  the  seat  of  the  primary 
tumor.     Since  the  above  was  written  I  have  seen  one  similar  case. 


w* 

1                       ' 

I ' v 

• 

f 

Fig.  196.  —  Inoperable  Sarcoma  Originating  in  the 
Lymph  Nodes  of  the  Neck.  (Bellevue  Hospital,  col- 
lection of  Dr.  L.  W.  Hotchkiss.) 


558  THE  NECK 

ANEURISMS   OF  THE   NECK 

Aneurisms  of  the  Common  Carotid  Artery. — Aneurisms  of  the  common 
carotid  artery  occur  from  wounds,  punctures  of  the  vessel,  and  gunshot  wounds, 
which  heal,  but  leave  a  weakened  arterial  wall;  from  subcutaneous  injuries 
which  bruise  or  tear  the  intima;  from  endarteritis  proceeding  from  the  ordi- 
nary causes — old  age,  alcoholism,  syphilis,  etc. ;  often  from  a  combination  of 
injury  and  disease.  Carotid  aneurism  is  rather  more  frequent  in  men  than 
women.  In  Crisp's  statistics  of  551  aneurisms,  20  involved  the  innominate, 
23  the  subclavian,  25  the  carotids.  The  common  carotids  are  much  more  often 
affected  than  the  external  or  internal.  According  to  Barwell,  in  87.35  per  cent 
of  the  cases,  7  per  cent  affected  the  external,  5.75  per  cent  the  internal  carotid. 
Any  part  of  the  common  carotid  may  be  the  seat  of  aneurism ;  the  extremities 
more  often  than  the  middle  part;  the  upper  extremity  more  often  than  the 
lower.  The  signs  and  symptoms  are  pulsation  and  pain  in  the  neck ;  later,  the 
formation  of  a  tumor,  usually  not  very  large,  spindle-shaped  or  ovoid  in  contour, 
giving  the  signs  of  aneurism ;  sometimes  enfeeblement  or  delay  of  the  temporal 
pulse.  Symptoms  due  to  circulatory  disturbances  in  the  brain — headache,  ver- 
tigo, sometimes  attacks  of  syncope,  disturbance  of  sleep.  Pressure  symptoms 
in  the  neck,  notably  paralysis  of  the  recurrent  laryngeal  nerve,  the  cervical 
sympathetic,  and  hypoglossal.  Disturbances  of  swallowing  and  breathing,  of 
greater  or  less  intensity,  and,  as  stated,  local  pain.  The  anatomical  situation 
of  the  tumor  usually  renders  these  aneurisms  and  their  seat  in  the  vessel  easy 
to  recognize ;  mistakes  may,  however,  occur.  If  the  sac  is  partly  consolidated, 
pulsation  may  be  feeble  or  wanting,  and  it  may  be  taken  for  a  glandular 
tumor  or  an  abscess  or  blood  cyst  communicating  with  a  vein.  Pain  and 
pressure  symptoms,  notably  paralysis  of  the  recurrent  laryngeal  nerve,  strongly 
favors  aneurism. 

Aneurism  of  the  External  Carotid. — Aneurism  of  the  external  carotid  is  rare. 
A  traumatic  origin  has  been  observed.  The  tumor  forms  behind  the  angle  of 
the  jaw  beneath  the  sterno-mastoid,  and  causes  a  bulging  in  the  pharynx. 
Pressure  symptoms  on  the  hypoglossal,  glosso-pharyngeal,  and  spinal  accessory 
nerves  may  be  present,  together  with  the  signs  of  aneurism. 

Aneurism  of  the  Internal  Carotid. — Aneurism  of  the  internal  carotid  is 
exceedingly  rare.  The  signs  and  symptoms  are  practically  the  same  as  those 
of  the  external  carotid.  Bulging  in  the  pharynx  may  be  marked  at  the  site 
of  the  tonsil,  and  the  aneurism  may  be  mistaken  for  an  abscess  or  a  tumor  in 
this  region. 

Aneurism  of  the  Innominate  Artery. — Aneurism  of  the  innominate  artery 
always  arises  from  pathological  changes  in  the  vessel  wall ;  since  wounds  of  the 
innominate  are  always  fatal,  traumatic  aneurisms  do  not  occur.  Any  portion 
of  the  vessel  may  give  origin  to  an  aneurism.  At  its  lower  end  the  aorta  may 
be  included  in  the  dilatation,  at  its  upper  end  the  right  carotid,  subclavian,  or 
both.     The  aneurism  may  be  either  fusiform  or  sacculated,  more  commonly 


ANEURISMS    OF   THE   NECK  559 

the  latter.  As  the  aneurism  increases  in  size,  it  may  remain  in  the  thorax, 
and  the  symptoms  will  consist  at  first  in  many  instances  of  dyspnea.  Examina- 
tion may  show  dullness  and  a  murmur  or  a  thrill,  or  both,  behind  the  sternum, 
or  the  X-rays  may  show  a  shadow  on  the  fluoroscope  or  in  a  radiograph.  If 
the  tumor  remains  in  the  thorax,  it  will  grow  forward  or  backward,  eroding 
the  ribs  and  sternum,  or  the  vertebra?,  and  causing  pressure  symptoms — dysp- 
nea, dysphagia,  etc.  If  the  growth  takes  place  upward,  it  will  appear  above 
the  right  sterno-clavicular  joint  and  give  the  ordinary  signs  of  aneurism.  The 
clavicle  may  be  eroded  or  its  sternal  end  dislocated.  The  pressure  symptoms 
on  the  trachea,  esophagus,  recurrent  laryngeal  nerve,  brachial  plexus,  sub- 
clavian, and  innominate  veins  give  rise  to  dyspnea,  dysphagia,  partial  paralysis 
of  the  larynx,  neuralgias  or  palsies  of  the  brachial  plexus,  edema  of  the  arm, 
etc. ;  pressure  symptoms  of  the  heart  and  aorta  and  of  the  carotid  and  sub- 
clavian arteries,  and  even  obliteration  of  the  two  latter  in  some  cases,  with 
cure  of  the  aneurism,  have  been  observed. 

It  is  very  easy  to  recognize  the  presence  of  the  aneurism,  not  always  so 
easy  to  tell  whence  it  has  arisen,  since  quite  similar  signs  and  symptoms 
may  follow  aneurism  of  the  aorta,  the  innominate,  the  first  portion  of  the 
carotid  or  subclavian.  A  simultaneous  modification  of  both  the  radial 
and  temporal  pulse  on  that  side  would  point  to  aneurism  of  the  innominate. 
The  history  of  the  site  at  which  the  tumor  first  appeared,  the  transmission  of 
the  bruit,  the  direction  in  which  the  tumor  grew,  might  aid  in  the  diagnosis. 
Innominate  aneurism  usually  ends  fatally  by  internal  rather  than  external 
rupture. 

Aneurism  of  the  Subclavian. — Aneurism  of  the  subclavian  is  occasionally 
traumatic,  resulting  either  from  a  punctured  wound,  or,  in  one  or  two  instances, 
from  blunt  violence  applied  above  the  clavicle.  In  these  latter  cases  death  has 
been  almost  immediate,  the  artery  having  been  ruptured  with  the  formation  of 
a  rapidly  increasing  arterial  hematoma.  The  spontaneous  aneurisms  of  the  sub- 
clavian do  not  differ  in  their  causation  from  other  spontaneous  aneurisms, 
although  it  is  believed  that  their  occurrence  might  be  determined  by  the  existence 
of  a  cervical  rib  by  pressure  on  the  arterial  wall.  They  occur  in  the  first  and 
third  portions  of  the  vessel.  The  aneurisms  of  the  first  portion  are  more  com- 
mon ;  they  occur  on  the  right  side,  more  rarely  in  the  intrathoracic  portion 
of  the  left  subclavian.  Aneurism  scarcely  arises  from  the  middle  portion 
of  the  subclavian ;  this  portion  may,  however,  take  part  in  the  dilatation  when 
the  first  or  third  part  becomes  the  seat  of  aneurism.  The  signs  and  symptoms 
of  aneurism  of  the  first  part  of  the  artery  are  hardly  to  be  distinguished  from 
those  of  innominate  aneurism.  Aneurism  of  the  third  portion  causes  the  appear- 
ance of  a  swelling  in  the  supraclavicular  region  behind  the  clavicle,  which  gives 
the  signs  of  aneurism.  The  radial  pulse  may  be  delayed  or  weakened ;  pressure 
upon  the  subclavian  vein  causes  edema  of  the  arm ;  pressure  upward  upon  the 
brachial  plexus  causes  neuralgias  or  paralysis  of  the  muscles  of  the  arm  and 
forearm. 


560  THE   XECK 

Aneurism  of  the  Vertebral  Artery. —  The  recorded  eases  of  aneurism  of  the 
cervical  portion  of  the  vertebral  artery  have  been  traumatic,  due  to  stab  and 
gunshot  wounds,  usually  of  the  back  of  the  neck.  The  aneurism  has  in  some 
cases  developed  as  an  arterial  hematoma  immediately  after  the  injury,  accom- 
panied by  the  formation  of  a  more  or  less  diffuse,  sometimes  a  circumscribed 
swelling  in  the  region  of  the  wound ;  pulsation  and  murmur  have  developed 
in  certain  cases.  In  a  number  of  instances  the  signs  of  aneurism  have  devel- 
oped slowly  and  not  until  many  days  after  the  injury.  Pressure  backward  on 
the  corresponding  side  of  the  front  of  the  neck  against  the  spine  below  the  sixth 
cervical  vertebra  has  usually  stopped  the  pulsation  in  the  tumor. 

Arterio-venous  Aneurism  between  the  Common  Carotid  and  the  Internal 
Jugular  Vein. — Arterio-venous  aneurism  between  the  common  carotid  and 
the  internal  jugular  vein  has,  in  a  moderate  number  of  reported  cases,  followed 
stab  and  gunshot  wounds  involving  these  vessels.  The  original  wound  has  usu- 
ally bled  profusely,  but  the  hemorrhage  has  been  checked  by  clotting  or  pres- 
sure. Marked  ecchymosis  is  usually  present  in  the  neck.  The  characteristic 
signs  and  symptoms  develop  in  the  course  of  from  one  to  ten  days,  occasionally 
later.  They  are  the  thrill  and  murmur,  continuous,  but  more  marked  during 
the  systolic  impulse.  They  are  felt  and  heard  by  the  patient,  often  to  a  dis- 
tressing degree.  If  the  communication  between  artery  and  vein  is  immediate 
(aneurismal  varix)  there  may  be  no  tumor  felt,  or  a  small  tumor,  circumscribed, 
rounded,  or  ovoid  in  shape.  Pulsation  may  be  expansile  or  not.  The  tumor 
is  soft,  and  may  be  made  to  disappear  entirely  on  pressure.  If  an  intermediate 
sac  forms  between  the  vessels  (varicose  aneurism),  the  tumor  may  be  of  irregu- 
lar shape  and  of  considerable  size.  It  will  usually  be  firmer  than  in  the  former 
case,  will  diminish  in  size  by  pressure,  but  cannot  be  made  to  disappear.  Pres- 
sure on  the  carotid  lower  down  in  the  neck  causes  cessation  of  pulsation,  thrill, 
and  murmur  in  either  case.  The  temporal  pulse  may  be  weaker  on  that  side. 
There  may  be  dilatation  of  the  superficial  veins  of  the  face  and  neck.  Cerebral 
symptoms  may  or  may  not  be  present,  according  to  the  extent  of  interference 
with  the  venous  circulation  in  the  interior  of  the  skull.  There  may  be  head- 
ache, vertigo,  confusion  of  mind.  The  continuous  murmur  may  produce  noises 
in  the  patient's  head,  such  that  he  is  unable  to  occupy  his  mind  with  work ; 
sleep  may  be  interfered  with.  These  symptoms  may  be  temporary  and  grad- 
ually pass  away,  or  continuous,  or  grow  progressively  worse.  The  tumor  may 
remain  quiescent  or,  in  the  case  of  varicose  aneurism,  the  sac  may  increase 
in  size  and  expose  the  patient  to  the  danger  of  rupture.  Pressure  on  the  recur- 
rent laryngeal  or  pneumogastric  may  cause  hoarseness,  cough,  etc. ;  generally 
speaking,  the  condition  is  far  less  threatening  than  is  the  case  with  ordinary 
aneurism.  The  question  of  operation  is  to  be  determined  by  the  gravity  of  the 
symptoms  in  the  individual  case. 

A  very  few  cases  of  arterio-venous  aneurism  of  the  external  and  internal 
carotid  arteries  have  been  observed.  From  what  has  been  stated,  the  diagnosis 
should  be  easy.     Arterio-venous  aneurism  of  the  subclavian  artery  and  vein 


TUMORS    OF   THE   NECK 


561 


occurs,  but  is  a  rarity ;  simultaneous  wounding  of  these  vessels  being  usually  a 
fatal  injury.  The  signs  and  symptoms  in  the  reported  cases  have  been  plain 
and  characteristic. 

TUMORS   OF   THE    NECK 

We  have  already  discussed  the  tumors  originating  in  the  lymphatic  glands. 
In  regard  to  tumors  of  the  neck  in  general,  it  may  be  said  that  they  are  fre- 
quent, of  a  very  varied  character,  and  originate  in  a  great  variety  of  structures. 
Their  complex  relations  are 
important  from  a  diagnos- 
tic and  therapeutic  point  of 
view.  Their  evident  attach- 
ment to  certain  structures 
frequently  gives  valuable 
diagnostic  aid,  and  the 
symptoms  produced,  when 
they  involve  or  press  upon 
blood-vessels,  nerves,  larynx, 
esophagus,  or  trachea,  often 
help  to  indicate  their  char- 
acter and  the  probable  dan- 
gers and  difficulties  of  their 
removal,  or  to  point  to  the 
probability '  that  such  re- 
moval will  be  either  im- 
practicable or  useless.  The 
details  of  these  relations  will 
be  discussed  as  this  chapter 
proceeds. 

The  Diagnosis  of  Malig- 
nant Tumors  of  the  Neck. — 
A  word  in  regard  to  the  di- 
agnosis of  malignant  tumors 
of  the  neck.  The  mere  ques- 
tion of  malignancy  is  usual- 
ly quite  easy  to  determine; 
the  question  of  oper ability  is 

not  so  readily  answered.  A  word  of  caution  may  not  be  out  of  place ;  a  malignant 
tumor  of  the  neck  nearly  always  extends  more  widely  and  deeply  into  the  tissues 
than  an  external  examination  would  indicate.  In  addition  to  the  mere  anatomical 
difficulties  to  be  met  with — and  they  are  often  great,  owing  to  the  displacements 
of  vessels  and  nerves — the  bleeding  is  apt  to  be  greatly  in  excess  of  what  would 
be  found  when  operating  on  a  normal  neck ;  and  an  inexperienced  operator  may 
find  himself  in  a  position  whence  he  can  neither  go  ahead  nor  easily  retire  from 
37 


Fig.   197. — Sarcoma  of  the  Neck,  Inoperable. 
(New  York  Hospital,  service  of  Dr.  Stimson.) 


562  THE   NECK 

a  very  difficult  position.  A  malignant  tumor  of  the  neck  which  seems  to  be 
on  the  borderland  of  operability  had  better  be  let  alone.  In  determining 
the  question  of  operability,  one  is  guided  largely  by  the  mobility  of  the  tumor. 
A  tumor  which  moves  freely  on  the  deeper  structures  is  probably  encapsulated, 
and  may  be  easily  removable,  even  though  of  large  size.  If  firmly  fixed  to  the 
vessels,  the  deeper  muscles,  the  trachea,  the  esophagus,  if  symptoms  of  paralysis 
of  the  recurrent  nerve,  the  sympathetic,  or  other  deep  nerve  trunks,  are  present, 
it  will  indicate  that  these  structures  are  pressed  upon  or  infiltrated  by  the  growth, 
and  that  difficulties  and  dangers  will  occur  during  the  operation  which  the 
careful  surgeon  will  anticipate  and  guard  against  as  far  as  may  be.  Evi- 
dence that  a  malignant  new  growth  of  the  neck  is  attached  to  the  skull  or  to 
the  cervical  vertebra?,  or  that  it  extends  below  the  level  of  the  sternum,  usually 
constitutes  an  absolute  contraindication  to  removal,  on  the  ground  that  such 
removal  must  necessarily  be  incomplete  and  without  advantage  to  the  patient. 

In  examining  a  tumor  as  to  its  mobility,  it  is  to  be  remembered  that  the 
movement  of  the  mass  should  be  attempted  in  the  line  of  the  vessels  or  in  the 
direction  of  the  muscular  fibers  respectively.  Motion  may  be  apparently  quite 
free,  at  right  angles  to  the  course  of  the  vessel  or  muscle,  and  yet  actually  these 
structures  are  moving  with  the  growth.  In  making  such  tests  the  muscle 
should  be  put  upon  the  stretch  if  possible.  Involvement  of  the  trachea  is 
indicated  by  dyspnea,  by  paralysis  of  the  recurrent  laryngeal  nerve,  by  whis- 
tling breathing,  and  by  the  fact  that  the  tumor  cannot  be  moved  upon  the 
trachea.  A  character  which  distinguishes  thyroid  tumors  from  all  others 
with  which  they  might  be  confounded  is  that  they  move  up  and  down  with 
the  larynx  during  the  act  of  swallowing.  After  a  tumor,  thyroid  or  other, 
has  pressed  upon  the  trachea  for  some  time,  absorption  or  softening  of  the 
tracheal  rings  takes  place.  There  may  be  dyspnea  from  flattening  of  the  tra- 
chea ;  or  the  tumor  may  hold  the  trachea  more  or  less  completely  open  by 
adhesions.  The  moment  such  a  tumor  is  removed  from  its  tracheal  attach- 
ments, the  trachea  will  collapse  with  fatal  results.  The  careful  surgeon  will 
anticipate  this  accident  by  tracheotomy,  or  be  ready  to  introduce  a  tracheal 
cannula  instantly  if  signs  of  imperfect  breathing  appear.  Involvement  of  the 
esophagus  is  indicated  by  dysphagia. 

Cystic  Tumors  of  the  Neck. — Brancliiogenic  Cysts. — Branchiogenic  cysts 
arise  from  the  persistence  of  some  intermediate  portion  of  the  second  branchial 
cleft  or  of  the  thyreo-glossal  duct,  the  outer  and  inner  terminations  of  these 
canals  being  closed.  (See  Congenital  Fistula?  of  the  ISTeck.)  The  cysts  arising 
from  the  second  cleft  occur  on  the  side  of  the  neck;  those  from  the  thyreo- 
glossal  duct  in  the  middle  line.  The  cysts  have  a  wall  of  more  or  less  dense 
fibrous  tissue,  containing  lymphoid  tissue  if  the  cyst  arises  from  the  inner 
embryonic  layer.  The  cysts  are  lined  with  pavement  epithelium  or  cylindrical 
ciliated  epithelium;  sometimes  with  a  membrane  containing  all  the  structures 
of  the  skin.  The  cysts  are  usually  unilocular,  occasionally  multilocular.  Their 
contents  varies ;  it  may  consist  of  clear  serous  fluid,  of  mucus,  of  oily  material, 


TUMORS    OF    THE   NECK 


563 


or  of  fatty  material  of  solid  or  semisolid  consistence,   hair  may  be   present, 
cholesterin  crystals,  etc. 

The  cysts  of  the  second  cleft  occur  between  the  hyoid  bone  and  the  sternum, 
usually  along  the  anterior  edge  of  the  sterno-mastoid  muscle.  They  are  of 
very  variable  size,  as  large  as  a 
pigeon's  egg,  or,  in  time,  they  may 
develop  into  large  tumors  occupy- 
ing much  of  the  side  of  the  neck. 
The  superficial  tissues  are  movable 
over  them,  but  they  have  often 
quite  firm,  deep  attachments  to  the 
sheath  of  the  vessels,  to  the  hyoid 
bone,  and  pharynx.  They  may  ap- 
pear at  any  time  of  life,  most  com- 
monly from  puberty  to  thirty  years 
of  age ;  they  grow  slowly ;  are 
neither  painful  nor  sensitive,  and 
are  only  unpleasant  on  account  of 
deformity.  They  are  smooth,  elas- 
tic tumors,  sometimes  translucent, 
usually  fluctuating,  and  have  to  be 
differentiated  chiefly  from  cold  ab- 
scess, rarely  from  lipoma,  blood 
cysts,  and  cystic  tumors  of  lym- 
phatic origin.  The  introduction  of 
an  aspirating  needle  will  usually 
decide  the  diagnosis.  The  contents  of  the  branchiogenic  cysts  are  as  described. 
If  they  contain  clear  fluid,  epithelial  cells  will  be  found  in  it. 

The  cysts  arising  from  the  thy reo- glossal  duct  are  usually  small.  They 
occur  in  the  median  line  of  the  front  of  the  neck  just  above  or  below  the  hyoid 
bone,  or,  more  rarely,  lower  down  as  far  as  the  sternum.  They  may  be  as  large 
as  a  pigeon's  egg,  rarely  larger  than  a  hen's  egg.  They  are  usually  attached 
to  the  hyoid  bone.  They  are  lined  with  flat  or  ciliated  epithelium.  Occasion- 
ally branchiogenic  cysts  undergo  suppuration.  They  are  also  the  seat  of 
degenerative  changes.  Carcinoma  may  develop  in  the  cyst  wall,  also  prolif- 
erating adenoma,  together  with  combinations  of  adenoma  and  lymphangioma. 

Congenital  Cystic  Hygroma  of  the  Neck — Congenital  Cystic  Lymphan- 
gioma.—The  tumor  consists  of  dilated  lymph  vessels  and  spaces  lined  with 
endothelium.  The  walls  of  the  cavities  consist  usually  of  a  very  thin  and  deli- 
cate fibrous  tissue.  The  contents  of  the  dilated  lymph  spaces  consist  of  clear 
or  slightly  milky,  watery  fluid,  sometimes  having  a  pale  brownish  tinge.  The 
size  of  the  individual  cavities  varies  from  minute  spaces  to  those  as  large  as 
a  good-sized  plum.  The  several  cavities  may  or  may  not  communicate  with 
one  another.     These  tumors  vary  greatly  in  size ;  at  birth  they  may  be  so  small 


Fig.  198.  —  Branchiogenic  Cyst  of  the  Neck 
arising  from  the  Second  Cleft.  (New  York 
Hospital,  service  of  Dr.  Frank  Hartley). 


564  THE   NECK 

as  not  to  be  noticed,  or  they  may  occupy  a  large  part  of  the  side  of  the  neck 
and  be  as  large  as  an  orange,  even  in  a  small  infant.  They  most  commonly 
are  situated  in  the  upper  part  of  the  neck  in  front  of  or  behind  the  sterno- 
mastoid  muscle,  but  may  occur  in  any  part  of  the  neck.  They  may  have  their 
origin  in  the  subcutaneous  connective  tissue,  or  in  the  deeper  structures  of  the 
neck — the  sheath  of  the  vessels,  for  example.  They  are  smooth  elastic  tumors, 
but  not  compressible,  and  may  thus  be  distinguished  from  cavernous  angioma. 
They  possess  a  peculiar  tendency  to  grow  and  spread  insidiously  along  the 
connective-tissue  planes.  The  trabeculated  or  cystic  lymphatic  tissue  gradually 
forces  its  way  between  the  trachea  and  esophagus,  surrounds  the  vessels,  in- 
vades the  intermuscular  planes  of  the  deep  muscles,  etc.  The  dangers  and 
difficulties  of  operative  removal  of  these  tumors  may  therefore  be  very  great. 
They  may  extend  downward  into  the  supraclavicular  fossa  or  into  the  axilla 
or  mediastinum.  Attacks  of  inflammation  may  occur  in  the  walls  of  the 
various  cavities,  sometimes  leading  to  obliteration  and  cure  of  portions  of 
the  tumor.     The  prognosis  is,  in  general,  not  very  favorable. 

Blood  Cyst  of  the  Neck. — A  cystic  tumor  containing  fluid  venous  blood  may 
occur  in  the  neck  from  a  diverticulum  of  a  large  vein,  from  hemorrhage  into 
some  form  of  cystic  tumor— branchiogenic  cyst,  lymphangioma,  or  be  devel- 
oped in  a  cavernous  angioma.  These  tumors  show,  on  aspiration,  a  content 
composed  of  venous  blood.  They  do  not  pulsate.  If  they  communicate  with 
a  vein,  they  are  reducible ;  if  of  other  origin,  they  are  not.  They  are  some- 
times congenital  tumors,  but  may  arise,  if  proper  antecedent  conditions  exist, 
at  any  time.  They  may  be  large  or  small.  They  occur  usually  beneath  the 
border  of  the  sterno-mastoid  at  any  level.  They  form  smooth,  rounded,  fluc- 
tuating swellings,  covered  by  normal  skin  and  fairly  movable.  They  grow  to 
a  certain  size,  and  remain  stationary,  or  continue  to  grow  and  spread,  even  as 
far  as  the  axilla.  The  diagnosis  of  a  cystic  tumor  containing  blood  is  easy. 
The  differential  diagnosis  as  to  its  origin  must  depend  upon  the  anatomical 
conditions  found  at  operation.  If  the  cyst  communicates  with  a  large  vein — 
internal  jugular  or  subclavian — it  will  be  increased  in  size  and  tension  by 
coughing,  straining,  crying,  etc. 

Subcutaneous  Atheromatous  Cysts  of  the  Neck. — Subcutaneous  atheromatous 
cysts  of  the  neck  occur  in  any  part  of  the  neck.  They  are  characterized  here, 
as  elsewhere,  by  their  slow  growth.  They  are  elastic,  rounded,  smooth  swell- 
ings, movable  on  the  parts  beneath,  but  adherent  at  one  point  to  the  skin.  They 
often  become  infected  and  suppurate. 

Cysts  of  the  Mucous  Bursas  of  the  Neck. — These  occur  in  the  vicinity  of 
the  hyoid  bone.  They  form  small  and  harmless  cystic  tumors  in  the  middle 
line  of  the  neck,  just  above,  or  more  often  just  below,  the  hyoid  bone,  or  on 
the  anterior  surface  of  the  thyroid  cartilage.  They  are  firmly  attached  to  the 
hyoid  bone  or  thyroid  cartilage,  and  move  with  the  larynx.  They  contain 
clear  fluid.  These  cysts  seldom  attain  a  size  larger  than  a  pigeon's  egg,  and 
usually  give  no  symptoms  unless  they  become  infected,  or  inflamed  by  mechan- 


TUMORS    OF    THE    NECK 


565 


ical  irritation.     A  differential  diagnosis  between  these  and  cysts  of  the  thyreo- 

glossal  duct  is  only  possible  by  a  microscopic  examination  of  the  cyst  wall. 
The  same  is  true  of  cysts  of  accessory  thyroids  in  this  situation  and  of  cysts 
of  the  so-called  suprahyoid  gland  (Zuckerkandl). 

Echinococcus  Cyst  of  the  Neck. — The  neck  is  a  rare  localization  for  this 
disease.  The  cyst  forms,  as  a  rule,  in  the  deeper  tissues  of  the  neck,  often  near 
the  sheath  of  the  vessels,  and  grows  outward  toward  the  surface,  forming  a 
tumor  which  presents  in  front  of  or  behind  the  sterno-mastoid  or  raises  this 
muscle  from  its  bed  and  forms  a  tumor  which  projects  to  the  front  and  rear. 
A  characteristic  of  these  cysts  is  an  intermittent  growth.  The  sudden  acces- 
sions in  the  size  of  the  tumor  are  attended  by  pain,  tenderness,  and  other  signs 
of  inflammation.  The  diagnosis  may  be  aided  by  the  presence  of  a  cystic 
tumor,  elastic  and  fluctuating,  which  shows  the  characteristic  thrill  or  vibra- 
tory sensation  transmitted  to  the  hand  when  the  tumor  is  sharply  tapped, 
although  this  sign  is  said  to  be  rarely  present  in  the  neck.  The  surface  may 
be  rounded  and  smooth  or  more  or  less  uneven  from  the  multilocular  charac- 
ter of  the  cyst.  The  use  of 
the  aspirating  needle  will 
show  the  presence  of  clear 
fluid  containing  the  hook- 
lets  of  the  worm.  (  See  Echi- 
nococcus.) In  the  neck,  as 
elsewhere,  echinococcus  may 
become  infected  and  suppur- 
ate. Although  these  cysts 
usually  grow  slowly  and 
intermittently,  in  time  they 
may  reach  a  large  size  and 
cause  serious  pressure 
symptoms,  even  oblitera- 
tion or  erosion  of  impor- 
tant vessels;  in  the  latter 
event  with  fatal  bleeding, 
as  has  happened  in  several 
cases.  If  they  extend  down- 
ward, pressure  on  the  bra- 
chial plexus  will  cause  neu- 
ralgias, palsies,  etc. 

Angiomata  of  the  Neck. 
— Angioma  simplex  (nevus 
vasculosus)  occurs  upon  the 
neck  in  various  situations, 
either  in  the  skin  or  subcutaneously,  and  is  to  be  recognized  here  as  else- 
where.     (See  Tumors.)      Angioma  cavernosum  occurs  in  the  neck  as  a  con- 


Fig.  199. — Multiple  Lipomata  of  the  Neck. 
(Author's  case.) 


566 


THE    NECK 


geries  of  dilated  veins  and  spaces  filled  with  venous  blood.  When  superficial 
the  recognition  is  easy.  (See  Tumors.)  When  deeply  placed  the  diagnosis 
is  scarcely  possible,  since  the  characteristic  signs  are  wanting,  until  the  growth 
approaches  the  surface. 

Cavernous  Lymphangioma. — Cavernous  lymphangioma  has  also  been  ob- 
served a  very  few  times  in  the  neck.  In  the  reported  cases  the  tumor  was 
in  the  supraclavicular  triangle  and  formed  a  soft  compressible  mass,  which 
could  hardly  be  differentiated  from  a  deep-seated  lipoma  or  a  cavernous 
angioma. 

Solid  Tumors  of  the  Neck  (Lipoma). — Lipoma  occurs  in  the  neck  in  both 
the  circumscribed  and  diffuse  forms.  The  circumscribed  lipomata  occur  espe- 
cially at  the  back  of  the  neck, 
where  they  form  sessile  or  pe- 
dunculated tumors  of  varying 
size.  Some  of  these  tumors  in 
time  grow  to  be  very  large.  In 
the  front  of  the  neck  they  may 
be  superficial  or  of  rather  deep 
origin,  so  that  they  raise  the 
sterno-mastoid,  and  project  in 
front  or  behind  the  muscle ; 
such  a  case  is  shown  in  the  il- 
lustrations. While  the  diag- 
nosis of  the  superficial  forms  is 
simple,  here  as  elsewhere  (see 
Tumors),  the  deep-seated  lipo- 
mata may  readily  be  mistaken 
for  other  forms  of  new  growth. 
Diffuse  lipoma  of  the  neck  oc- 
curs almost  exclusively  in  men 
of  middle  age.  The  neck  is 
surrounded  by  rounded  or  more 
flat  diffuse  masses  of  fatty  tis- 
sue producing  marked  deform- 
ity and  much  annoyance  on  ac- 
count of  the  mere  size  of  the 
tumors.  Pressure  symptoms  are 
rare  (see  illustration). 
Fibroma  of  the  Neck. — Fibroma  molluscum,  large  and  diffuse,  or  small 
and  circumscribed,  sessile  or  pedunculated,  occurs  upon  the  neck  in  various 
situations ;  its  recognition  is  easy.  They  are  sometimes  combined  with  plexi- 
form  neurofibroma.  (See  Fibroma.)  More  deeply  placed  fibroma,  arising 
for  the  most  part  from  fascial  planes,  occurs  notably  in  the  back  of  the  neck; 
the  tumors  are  slowly  growing,  firm  masses  of  fibrous  tissue.     In  the  side  of 


Fig.  200.- 


-Superficial  Lipoma  of  the  Neck. 
(Author's  case.) 


TUMORS    OF   THE   KECK 


567 


the  neck  they  usually  arise  from 
the  connective-tissue  sheaths  of 
vessels  and  nerves,  and  are  pres- 
ent beneath  the  sterno-mastoid.  In 
the  front  of  the  neck  they  are  ex- 
ceedingly rare.  The  diagnosis  of 
these  fibrous  tumors  is  not  diffi- 
cult; they  are  too  firm  in  consist- 
ence for  lipoma ;  they  grow  too 
slowly  to  be  sarcomata,  and  the  in- 
filtration and  widespread  adhesions 
of  malignant  growths  are  wanting. 
Chondroma  and  Osteoma. — 
Chondroma  and  osteoma  are  occa- 
sionally observed  in  the  lower  part 
of  the  neck,  arising  from  the  cer- 
vical vertebrae,  the  first  rib,  or  the 
clavicle.  They  are  hard,  immov- 
able tumors  of  slow  growth,  at- 
tached to  bone.  They  may  give 
rise  to  pressure  symptoms.  The 
diagnosis  of  osteoma  might  be  aid- 
ed by  an  X-ray  picture. 


Fig.  202.  —  Lipoma  of  the  Supraclavicular 
gion.     (Collection  of  Dr.  Charles  McBurney. 


Re- 


Fig.  201. — Lipoma  of  the  Neck  Deeply  Placed 
Beneath  the  Sternomastoid  Muscle,  an  Un- 
usual Situation.  (Collection  of  Dr.  Charles 
McBurney,  Roosevelt  Hospital.) 


Neuroma. — Isolated  neurofibro- 
ma may  occur  in  the  superficial  or 
deep  nerves  of  the  neck,  and  form 
quite  large  tumors,  giving  rise  to 
symptoms  of  paralysis  or  irritation. 
Plexiform  neuroma  is  more  com- 
mon, and  may  affect  superficial  or 
deep  nerves.  The  superficial  form 
has  already  been  spoken  of  else- 
where. The  peculiar  appearances 
of  thickening  of  the  skin,  pigmenta- 
tion, and  the  soft,  cordlike  masses 
beneath  the  skin  are  characteristic. 
In  the  deep  form  the  diagnosis  is 
not  likely  to  be  made  until  opera- 
tion is  undertaken.  I  once  assisted 
Dr.  Robert  Abbe  at  an  operation 
upon  a  case  of  this  kind.  The  pa- 
tient was  a  little  girl,  and  the  large, 
partly  nodular  and  firm,  partly  cord- 
like and  soft  masses  formed  a  con- 


568 


THE   NECK 


siderable  tumor  in  the  neck  beneath  the  sterno-mastoid  muscle  and  behind  the 
vessels,  extending  from  the  hyoid  bone  to  the  clavicle  and  below  it.  The 
growth  originated  in  the  cervical  sympathetic. 

Sarcoma  of  the  Neck. — Lymphosarcoma  of  the  neck  has  already  been  de- 
scribed. The  skin  {pigmented  moles),  the  muscles,  bones,  and  connective- 
tissue  planes  of  the  neck  may  all  be  the  starting  point  of  sarcoma  of  various 
types.  These  tumors  are  characterized  here  as  elsewhere  by  all  the  signs  and 
symptoms  peculiar  to  malignant  new  growths,  already  sufficiently  described 
under  Tumors. 

Carcinoma  of  the  Neck. — Carcinoma  of  the  neck  occurs  superficially  as 
epithelioma,   the  characters   of  which  have  been  sufficiently  described  under 

*  Tumors.  Epithelioma  of 
the  neck  is  very  rare  as 
compared  with  similar 
new  growths  upon  the 
face.  Cancer  may  also 
occur  as  deep-seated  car- 
cinoma having  an  origin 
other  than  in  the  skin; 
these  latter  arise  in  a 
variety  of  situations, 
notably  from  carcinom- 
atous degeneration  in  the 
walls  of  branchiogenic 
cysts,  further  in  acces- 
sory thyroid  glands. 
These  tumors  are  not 
numerous,  comparatively 
few  cases  having  been 
observed.  They  have  all 
occurred  in  elderly  men. 
The  tumor  has  been  situ- 
ated in  the  majority  of 
the  cases  in  the  upper 
part  of  the  neck,  and  has  presented  as  a  hard  nodule  beneath  the  sterno- 
mastoid  muscle.  The  growth  has  been  rapid,  attended  by  marked  pain,  by 
early  infiltration  of  the  surrounding  structures,  notably  early  adhesion  to  the 
sterno-mastoid,  early  infection,  enlargement  and  induration  of  the  neighbor- 
ing lymphatic  glands,  by  adhesion  to  and  perforation  of  the  skin,  ulceration, 
hemorrhage,  and  the  rest  of  the  dismal  story  common  to  cancers.  The  early 
diagnosis  of  these  carcinomata,  except  by  operative  removal,  is  not  likely  to  be 
made.  Nodular  tumors  in  this  vicinity,  such  as  lymphomata,  tubercular  or 
other,  are  very  common,  while  this  form  of  carcinoma  is  exceedingly  rare. 


Fig.  203. — Malignant  Type  of  Epithelioma  of  the  Neck,  in  a 
Young  Man  Aged  Twenty-six.     (Author's  case.) 


DISEASES    AND    TUMORS    OF    THE    THYROID    GLAND 


569 


DISEASES   AND    TUMORS   OF   THE   THYROID    GLAND 

Exophthalmic  Goiter  (Graves's  Disease — Basedow's  Disease).  —  The 
pathology  of  Graves's  disease  is  not  certainly  known.  A  theory  which  has 
met  with  rather  wide  acceptance  is  that  the  symptoms  are  due  to  a  toxemia 
caused  by  the  absorption  of  an  increased  or  altered  secretion  from  the  thyroid 
gland.  The  signs  and  symptoms  of  the  disease  are:  (1)  Enlargement  of  the 
thyroid  gland.  (2)  Protrusion  of  the  eyeballs.  (3)  Tachycardia  (an  in- 
creased rapidity  in  the  pulse  rate).  (4)  Other  associated  symptoms,  constant 
and  inconstant.  The  disease  is  much  more  frequent  in  women  than  men. 
The  patients  are  often  neurotic  or  hysterical  individuals.  Anemia,  hemor- 
rhage, and  other  depressing  conditions  appear  sometimes  to  act  as  predispos- 
ing causes,  as  do  profound  emotional  disturbances. 

1.  The  enlargement  of  the  thyroid  may  be  marked  or  moderate,  and  is 
usually  symmetrical.  Its  consistence  is  soft  or  of  medium  firmness.  The 
size  is  rarely  great  enough  to  produce  pressure  symptoms. 

2.  Exophthalmos  may  be  marked,  moderate,  or,  rarely,  absent.  There  is 
an  increase  in  the  size  of  the  space  between  the  lids ;  when  the  patient  is  directed 
to  look  downward,  the  upper  lid  in  its  motion  lags  behind  the  eyeball.  There 
is  absence  of  the  power  to  converge  the  axes  of  the  two  eyes — i.  e.,  the  patient 
cannot  look  at  the  end  of  her  nose  with  both  eyes  at  once;  when  directed  to 
do  so,  the  eyes  turn  to  the  right  or 
to  the  left,  but  only  one  eye  turns 
toward  the  middle  line.  The  pa- 
tient winks  less  often  than  normal. 

3.  The  action  of  the  heart  is 
rapid — 120-140  beats  a  minute  or 
more.  Palpitation  and  tumultuous 
action  of  the  heart  occur  from  slight 
mental  or  physical  disturbances. 
Attacks  of  angina  pectoris  occur  in 
bad  cases  associated  with  myocar- 
ditis. 

4.  Diarrhea  of  a  serious  and 
even  fatal  character  may  occur. 
Nervous  symptoms. — A  constant 
symptom  is  muscular  tremor,  not 
unlike  that  of  chronic  alcoholism, 
most  marked  in  the  hands,  but  also 
involving  the  muscles  of  the  trunk. 
Choreic  movements  may  be  present. 
Hysterical  attacks  are  common,  as 
are  nervous  irritability  and  other  symptoms  of  neurasthenia.  To  be  men- 
tioned also  are  increased  secretion  of  sweat,  vasomotor  disturbances,  flushing, 


Fig.  204. — Exophthalmic  Goiter. 
(Case  of  Dr.  William  Downs.) 


570  THE   NECK 

edema,  pigmentation.  The  patients  often  become  anemic,  suffer  from  muscu- 
lar weakness  and  emaciation.  The  disease  is  fatal  in  a  considerable  propor- 
tion of  those  cases  which  run  an  acute  course,  chiefly  from  conditions  refer- 
able to  degeneration  of  the  heart  muscle.  In  other  cases  diarrhea  constitutes 
a  serious  menace  to  life.  It  is  to  be  borne  in  mind  that  any  one  of  the  char- 
acteristic symptoms  of  the  disease  may  be  absent ;  further,  that  other  varieties 
of  goiter  and  cysts  and  tumors  of  the  thyroid  gland  may  be  associated  with  the 
symptoms  of  exophthalmic  goiter. 

Cretinism,  Myxedema,  and  Cachexia  Strumipriva. — In  certain  localities, 
where,  owing,  apparently,  to  some  quality  in  the  water  supply,  diseases  of  the 
thyroid  gland  are  endemic  and  frequent,  children  are  born,  apparently  normal 
at  birth,  who  do  not  develop  normally  either  in  stature  or  intelligence.  They 
are  dwarfs;  the  special  senses  are  blunted;  they  are  often  deaf;  they  may 
never  learn  to  speak ;  they  suffer  from  peculiar  nutritive  disturbances  of  the 
skin  and  its  appendages.  In  such  cases  the  thyroid  gland  is  found  to  be 
atrophied  or  nearly  absent,  in  some  cases  enlarged  but  fnnctionless.  These 
unfortunates  are  known  as  "  cretins  " ;  they  are  practically  idiots.  The  condi- 
tion is  not  a  surgical  one,  and  therefore  is  not  described  at  length. 

Myxedema  is  a  corresponding  condition  occurring  in  adults  who  suffer 
from  atrophy  of  the  thyroid  gland,  and  cachexia  strumipriva  is  an  analogous 
condition  which  follows  the  total  operative  removal  of  the  thyroid,  rarely 
tumors  and  disease  of  that  organ.  A  few  words  in  regard  to  this  condition 
may  not  be  out  of  place.  In  a  certain  number  of  cases  the  removal  of  the 
thyroid  has  been  followed  in  hours  or  after  a  few  days  by  tetanic  spasms  of 
the  voluntary  muscles,  first  of  the  upper  extremities,  then  of  the  lower,  spread- 
ing to  the  neck  and  trunk,  finally  to  the  diaphragm,  and  ending  in  death  in  a 
large  proportion  of  cases.  The  tetanic  contractions  occur  in  attacks  of  variable 
duration,  and  in  the  fatal  cases  after  diminishing  intervals.  As  a  means  of 
early  diagnosis  may  be  mentioned  Trousseau's  phenomenon — namely,  if  a  large 
blood-vessel  or  nerve  trunk  be  compressed  in  an  extremity  for  a  minute  tetanic 
spasms  of  the  muscles  are  produced ;  further,  a  tap  or  light  stroke  in  front 
of  the  ear  causes  sudden  violent  contraction  of  the  muscles  supplied  by  the 
facial  nerve  of  that  side. 

In  other  cases  death  does  not  occur,  and  the  condition  goes  on  to  assume  a 
chronic  form,  about  to  be  described,  known  as  cachexia  strumipriva.  The 
lamentable  state  may  follow  immediately  the  removal  of  the  thyroid,  usually 
it  is  gradually  developed  after  weeks  or  months;  the  symptoms  are  essentially 
the  same  as  those  of  myxedema.  Milder  forms  may  follow  partial  removals 
of  the  thyroid.  After  a  period  of  health  of  variable  duration  following 
removal  of  the  thyroid,  the  individual  gradually  passes  into  a  state  of  mental 
apathy,  loses  all  interest  in  life.  There  is  a  gradual  abolition  of  physical 
and  mental  energy ;  the  temperature  of  the  body  is  subjectively  and  objectively 
lowered.  There  is  edematous  thickening  of  the  skin.  The  skin  of  the  face 
becomes  swollen,  thickened,  and  waxy  in  color.     There  is  cessation  of  secre- 


DISEASES    AND    TUMORS    OE    THE    THYROID    GLAND  571 

tion  in  the  sweat  and  sebaceous  glands.  The  face  loses  all  liveliness  of  expres- 
sion; the  patient  looks  dull  and  stupid.  The  edema  differs  from  ordinary- 
serous  infiltration  in  that  the  tissues  do  not  pit  on  pressure.  The  hair  falls, 
often  completely.  The  swollen  dry  condition  of  the  skin  extends  to  the  trunk 
and  extremities.  There  is  often  marked  edematous  swelling  in  the  supra- 
clavicular region.  The  mucous  membrane  of  the  mouth  and  throat  is  often 
swollen,  so  that  speech  is  interfered  with.  There  is  diminished  cutaneous  sen- 
sibility. There  is  usually  anemia,  diminution  in  the  number  of  red  cells  and 
of  hemoglobin  of  a  moderate  degree,  and  slight  leucocytosis.  The  sexual  organs 
undergo  atrophy  or  cease  to  functionate.  The  mental  condition  gradually 
grows  worse  until  the  patients  are  in  a  condition  of  stupor  from  which  they 
can  scarcely  be  roused.  In  young  persons  the  symptoms  are  most  marked  and 
acute  in  their  course.  The  growth  of  the  bones  in  length  is  interfered  with. 
Untreated,  these  cases  end  fatally  after  an  interval  which  may  extend  over  a 
period  of  years. 

Acute  Inflammation  of  the  Thyroid  Gland. — Either  the  normal  gland,  or 
more  often  a  gland  the  seat  of  one  or  other  of  the  forms  of  goiter,  may  become 
inflamed  as  the  result  of  an  infected  wound ;  further,  as  a  metastatic  process 
in  the  course  of  any  of  the  acute  infectious  diseases — typhoid,  pyemia,  sep- 
ticemia, the  exanthemata,  diphtheria,  erysipelas,  and  acute  inflammations  of 
the  alimentary  canal.  The  symptoms  are  those  of  localized  pus  infection  and 
more  or  less  marked  sepsis.  Local  pain,  tenderness,  and  swelling,  followed  by 
redness  of  the  skin  and  fluctuation  if  an  abscess  makes  its  way  to  the  surface. 
Such  an  abscess  may  burst  into  the  trachea  or  esophagus,  or  burrow  down- 
ward into  the  mediastinum.  Incision  may  permit  the  escape  of  pus  or  of  a 
more  or  less  extensive  slough  of  the  gland  tissue.  Pressure  symptoms,  dyspnea, 
etc.,  are  not  uncommon. 

Syphilis. —  The  thyroid  may  be  swollen  during  the  early  months  of  syphilis. 
The  enlargement  is  transitory  and  not  marked.  Gumma  of  the  thyroid 
occurs  as  a  nodular  or  more  diffuse  and  sometimes  rather  rapidly  growing 
hard  tumor  of  the  gland  accompanied  by  a  good  deal  of  pain  and  by  pressure 
symptoms,  dyspnea,  and  symptoms  of  pressure  on  the  recurrent  laryngeal  nerve. 
The  diagnosis  of  a  malignant  growth  can  only  be  excluded  by  the  use  of  iodid, 
or  by  the  presence  of  other  evidences  of  syphilis. 

Tubercular  Inflammation  of  the  Thyroid  Gland. — Miliary  tubercles  may  be 
present  in  the  gland  during  acute  general  miliary  tuberculosis.  Circumscribed 
or  diffuse  areas  of  tubercular  infiltration  may  occur  as  a  localized  process  in 
the  gland.  I  have  seen  one  such  case.  One  half  the  thyroid  was  involved  and 
was  swollen,  hard,  and  nodular.  Operation  disclosed  areas  of  caseation  of 
considerable  size,  and  submiliary  and  larger  tubercles  scattered  throughout  the 
substance  of  the  gland.  The  patient  was  a  young  woman  who  showed  other 
evidences  of  tuberculosis,  as  has  been  regularly  observed  in  these  cases. 

Echinococcus  of  the  Thyroid. — Echinococcus  of  the  thyroid  has  been  ob- 
served.    There  are  no  positively  distinctive  diagnostic  features  other  than  have 


572    '  THE   NECK 

been  spoken  of  under  Echinococcus.  Fatal  perforation  into  the  trachea  has 
taken  place  in  a  number  of  cases,  and  that  before  the  cysts  had  reached  a  very 
large  size. 

Bronchocele.  Goiter. — Benign  enlargements  of  the  thyroid  gland,  whether 
they  involve  the  whole  or  only  a  part  of  the  gland,  are  known  by  the  general 
name  of  goiter.  If  the  enlargement  is  malignant  (carcinoma-sarcoma),  that 
adjective  is  prefixed.  Although  the  pathology  of  the  thyroid  is  rather  com- 
plicated, it  appears  necessary  to  speak  of  it  at  some  length,  for  a  recognition 
of  the  character  of  the  various  lesions  has  an  important  bearing  on  the  surgical 
treatment.  The  enlargement  of  the  gland  may  be  diffuse  or  partial.  The 
diffuse  hypertrophies  may  involve  the  parenchyma,  the  stroma,  or  the  blood- 
vessels, or  all  three.  In  the  last  case  the  gland  is  simply  increased  in  size,  the 
relative  proportion  of  the  structures  of  which  it  is  composed  remains  normal 
(parenchymatous  goiter),  or  the  contents  of  the  glandular  follicles  are  in- 
creased in  quantity  (follicular  diffuse  goiter).  The  contents  of  the  gland  folli- 
cles may  undergo  colloid  degeneration,  and  the  process  may  be  accompanied 
by  the  fusion  of  several  follicles  into  one  larger  space  (diffuse  colloid  goiter). 
Less  commonly  the  fibrous  stroma  of  the  gland  is  increased  in  amount  at  the 
expense  of  the  glandular  elements.  The  gland  becomes  hard  and  nodular,  and 
often  diminished  in  size.  When,  along  with  an  increase  in  the  glandular 
elements,  arteries  or  veins  or  both  are  notably  increased  in  size,  we  sometimes 
speak  of  a  "  vascular  goiter." 

Partial  Hypertrophies. — The  changes  are  the  same  as  in  the  diffuse 
forms,  but  are  limited  to  a  circumscribed  portion  of  the  gland.  In  these  areas 
of  hyperplasia,  cysts  may  be  formed  either  by  absorption  of  the  walls  of  con- 
tiguous follicles,  or  from  hemorrhages,  or  from  necrosis  of  a  limited  area  of 
tissue.  The  cysts  may  be  single  or  multiple,  close  together,  or  scattered  through- 
out one  or  both  lobes  of  the  gland.  They  vary  in  size  from  that  of  a  pea  to 
an  orange  or  larger.  In  the  first  variety  the  wall  of  the  cyst  is  at  first  thin 
and  delicate;  later  it  may  become  thickened  and  fibrous.  Calcareous  degen- 
eration may  take  place  in  the  cyst  wall ;  rarely  thin,  bony  plates  may  be  devel- 
oped. So  long  as  the  interior  of  the  cyst  is  lined  with  epithelium,  the  contents 
of  the  cyst  may  increase  in  quantity  and  the  cyst  increase  in  size.  The  con- 
tents of  the  cysts  may  be  colloid  material,  the  consistence  of  which  may  be 
thin  and  watery,  or  semifluid  and  viscid,  or  soft  solid,  and  may  contain  choles- 
terin  crystals.  If,  as  often  happens,  bleeding  occurs  into  the  interior  of  the 
cysts,  the  color  and  consistence  will  be  thin,  brown,  and  tnrbid,  or  thick,  pasty, 
and  chocolate-colored,  etc.,  according  to  the  amount  of  blood  and  colloid  mate- 
rial respectively.  In  those  cysts  which  arise  primarily  from  hemorrhage  into 
the  substance  of  the  gland,  the  contents  are  often  brown,  pasty  material,  or  in 
some  cases  lime  salts  are  deposited  in  the  ancient  blood  clot  to  a  variable  extent, 
producing  dry,  puttylike  masses,  or  hard  calcareous  nodules.  The  place  of  such 
blood  clots  may  be  taken  by  firm  fibrous  tissue  forming  fibrous  nodules  in  the 
gland.     The  connective-tissue  stroma  of  the  hyperplastic  portion  of  gland  sub- 


DISEASES    AND   TUMORS    OF   THE    THYROID    GLAND 


573 


stance  may  undergo  hyaline  degeneration.  Any  or  all  of  these  changes  may 
go  on  at  once  in  separated  areas  of  the  gland,  or  in  adjacent  areas.  There 
occur,  further,  circumscribed  nodular  tumors  of  the  thyroid,  either -congenital 
or  developed  first  at  puberty,  the  tissue  of  which  departs  from  the  normal  in 
that  it  preserves  the  fetal  type  of 
gland    tissue    (Wol tier's   fetal    ade- 


Fig.  205. — Parenchymatous  Goiter. 
(Author's  case.) 


Fig.    206.  —  Parenchymatous    Goiter. 
(Collection  of  Dr.  Charles  McBurney.) 


noma).  Also  tubular  adenomata,  preserving  the  fetal  type  of  tissue,  and 
tubular  adenomata,  in  which  the  tubules  are  lined  with  cylindrical  epithelium. 
These  constitute  the  benign  forms  of  goiter. 

Accessory  Thyroids. — Portions  of  thyroid  tissue  may  occur  in  various 
situations,  either  connected  with  the  thyroid  gland  by  a  bridge  of  fibrous  tissue 
or  as  independent  masses.  In  the  former  case  their  relation  to  the  thyroid  is 
in  most  instances  easy  to  recognize.  They  move  with  the  thyroid  and  trachea 
during  the  act  of  swallowing,  or  their  connection  can  be  demonstrated  on 
manipulation.  In  the  latter  case  the  diagnosis  is  often  impossible.  Accessory 
thyroids  were  classified  by  Madelung  into  inferior,  posterior,  superior,  and 
anterior  accessory  thyroids.  The  inferior  group  may  be  substernal,  intra- 
thoracic, or  retroclavicular.  The  retrosternal  are  the  most  frequent ;  they  are 
usually  connected  with  the  thyroid  isthmus  by  a  band  of  fibrous  tissue.  The 
posterior  occur  between  the  esophagus  and  vertebra?,  and  may  give  rise  to  diffi- 
culty in  swallowing.  The  superior  may  occur  above  the  hyoid  bone  or  at  the  base 
of  the  tongue.  The  anterior  accessory  thyroids  are  exceedingly  rare ;  the  term 
has  been  used  to  designate  the  rare  cases  in  which  an  accessory  thyroid  connected 
with  the  thyroid  isthmus  has  descended  under  the  skin  of  the  thorax  in  front  of 
the  sternum  instead  of  assuming  a  retrosternal  situation,  as  is  commonly  the  case. 


574  THE   NECK 

Symptoms. — The  symptoms  produced  by  enlargements  of  the  thyroid  de- 
pend upon  the  size  and  situation  of  the  tumor  and  the  rapidity  of  its  growth, 
and  are  chiefly  due  to  pressure  upon  surrounding  organs — trachea,  esophagus, 
blood-vessels,  and  nerves.  Respiratory  symptoms  may  be  slight  or  marked. 
If  the  tumor  is  considerable  in  size,  dyspnea  on  exertion  will  be  complained 
of,  accompanied  by  whistling  breathing;  there  may  also  be  attacks  of  severe 
dyspnea,  which  come  on  without  warning  and  may  awaken  the  patient  out  of 
his  sleep.  Such  attacks  may  be  alarming,  or  even  fatal.  They  may  be  due 
to  compression  of  the  trachea  or  to  pressure  upon  the  nerves  of  the  larynx. 
The  recurrent  laryngeal  may  be  compressed  upon  one  or  both  sides.  If  one 
nerve  is  paralyzed,  one  vocal  cord  cannot  be  abducted.  Disturbance  of  voice 
and  dyspnea  are  the  result.  If  both,  such  dyspnea  may  be  fatal.  These  pa- 
tients suffer  from  aphonia.  The  retrosternal  thyroid  tumors,  and  those  which 
surround  the  trachea,  are  especially  liable  to  cause  such  symptoms.  The  com- 
pression of  the  trachea  by  tumors  of  the  thyroid  is  of  several  types.  If  the 
tumor  surrounds  the  trachea  the  compression  may  be  circular;  the  caliber  of 
the  trachea  in  the  compressed  area  is  symmetrically  diminished.  Lateral  com- 
pression is  more  common  from  one  or  both  sides.  If  the  pressure  is  unilateral, 
the  trachea  may  be  narrowed  from  side  to  side  and  sharply  bent ;  a  perilous 
condition,  attended  by  the  danger  of  sudden  collapse  of  the  trachea  and  death 
from  asphyxia.  Bilateral  compression  may  cause  the  trachea  to  be  narrowed 
to  a  mere  slit,  broader  in  front  than  behind ;  in  this  condition  the  trachea 
has  been  likened  to  the  scabbard  of  a  saber.  Intrathoracic  goiters,  either  in 
front  of  the  trachea  or  behind  the  esophagus,  may  compress  the  trachea  against 
the  vertebras  or  the  sternum,  respectively.  It  is  to  be  remembered  that  all  these 
forms  of  compression,  if  prolonged,  are  attended  by  softening  and  absorption 
of  the  cartilaginous  tracheal  rings.  Irritation  of  the  recurrent  nerves  may 
cause  spasm  of  the  larynx,  with  spasmodic  cough,  hoarseness,  and  dangerous 
dyspnea.  Pressure  upon  the  cervical  sympathetic  will  cause  irritation  or  paral- 
ysis of  that  nerve  trunk,  with  corresponding  symptoms  (see  Injuries  of  the 
Cervical  Sympathetic).  Pressure  symptoms  upon  the  main  trunk  of  the  pneu- 
mogastric  are  rare  except  from  tumors  which  surround  the  trachea  or  lie  behind 
the  esophagus,  and  in  malignant  tumors  of  the  thyroid.  The  most  notable 
symptoms  of  irritation  of  the  pneumogastric  is  tachycardia.  Pressure  upon 
the  lower  cervical  nerves  may  cause  neuralgic  pain  in  the  arm.  Pressure  symp- 
toms on  the  gullet  are  confined  to  those  thyroid  nodules  which  grow  backward 
chiefly  upon  the  left  side,  to  circular  goiters  surrounding  the  trachea,  and  to 
accessory  thyroids  behind  the  esophagus  and  to  malignant  tumors.  The  symp- 
toms are  rarely  urgent.  There  may  be  pain  in  swallowing,  but  there  is  rarely 
difficulty  in  swallowing  solid  food.  Although  the  thyroid  arteries  are  often 
notably  increased  both  in  length  and  caliber  in  the  presence  of  large  goiters, 
no  symptoms  other  than  increased  pulsation  are  ordinarily  produced.  The 
carotids  are  displaced  backward  and  outward  as  the  tumor  grows,  and  may  often 
be  felt  and  seen  pulsating  behind  the  sterno-mastoid  muscle,  sometimes  quite  su- 


DISEASES   AND    TUMORS    OF   THE   THYROID    GLAND 


575 


perficially.  Pressure  upon  the  veins  causes  congestion,  often  cyanosis  of  the  face, 
by  obstruction  to  venous  return,  notably  in  goiter  occupying  the  superior  aperture 
of  the  thorax.  The  cyanosis  is  most  marked  after  muscular  effort.  While  the 
patient  is  quiet  the  face  is  often  notably  pale.  In  some  cases  there  may  be  ede- 
ma of  the  arm  and  swelling 
of  the  mucous  membrane  of 
the  mouth.  There  is  often 
dilatation  of  the  right  side 
of  the  heart  (tachycardia 
and  palpitation).  The  su- 
perficial and  deep  veins  of 
the  neck  are  often  dilated. 

Differential  Diagno- 
sis of  Goiter. — The  mere 
enlargement  of  a  normally 
placed  thyroid  gland, 
whether  diffuse  or  circum- 
scribed, is  easily  recognized. 
The  anatomical  situation  of 
the  tumor  and  the  fact  that 
it  moves  up  and  down  with 
the  larynx  during  the  act 
of  swallowing  is  enough  to 
connect  it  with  the  thyroid  gland.  Inspection  of  the  individual  and  of  the  neck 
gives  much  information.  If  the  enlargement  is  symmetrical  and  is  associated 
with  exophthalmos,  the  diagnosis  of  exophthalmic  goiter  needs  only  a  brief  in- 
quiry into  the  subjective  symptoms  and  history  to  render  it  certain.  We  are 
further  able  to  note  the  size  and  situation  of  the  tumor,  whether  it  affects  one  or 
both  lobes  or  the  isthmus.  Pressure  on  the  veins  is  indicated  by  cyanosis  or 
congestion  of  the  face  and  dilated  subcutaneous  veins.  Paralysis  of  the  sympa- 
thetic is  indicated  by  a  contracted  pupil,  partial  ptosis,  flushing  of  the  affected 
side  of  the  face,  etc.  Irritation  causes  a  dilated  pupil,  sometimes  exophthal- 
mos, paleness  of  the  skin,  etc.  By  palpation  we  determine  the  mobility  of 
the  tumor.  Unless  a  thyroid  is  very  large  or  is  wedged  into  the  superior  aper- 
ture of  the  thorax,  or  is  one  of  the  rare  congenital  forms  which  surrounds  the 
trachea,  it  is  usually  quite  movable.  Immobility  suggests  malignancy.  Adhe- 
sion of  the  skin  to  the  tumor  indicates  malignancy  or  inflammation.  The 
consistence  is  best  tested  by  palpation  with  both  hands.  The  presence  of  cysts, 
of  hard,  fibrous  nodules,  may  be  thus  detected.  The  position  of  the  larynx 
and  trachea,  whether  displaced,  bent,  or  compressed,  may  be  determined  more 
or  less  accurately  in  the  same  manner.  By  auscultation,  whistling  or  harsh 
breathing  may  be  heard,  indicating  compression  of  the  trachea  or  involvement 
of  the  nerves  of  the  larynx.  In  some  very  vascular  goiters  a  soft  systolic 
murmur  may  be  present  over  the  tumor. 


Fig.  207. — Cystic  Goiter  of  Rather  Large  Size.  Circum- 
ference of  the  neck  17J  inches.  (Collection  of  Dr.  Charles 
McBurney.) 


576 


THE   NECK 


Laryngoscopic  Examination. — If  one  or  both  recurrent  nerves  are  pressed 
upon,  or  unduly  stretched  by  the  tumor,  the  laryngoscopic  picture  may  show 
one  or  both  vocal  cords  paralyzed  so  that  they  cannot  be  abducted.  In  some 
cases  displacement  or  narrowing  of  the  trachea  may  be  recognizable  through 
laryngoscopic  examination.  The  presence  of  a  thyroid  tumor  being  established, 
it  is  desirable  to. determine  its  character.  In  the  United  States,  diffuse  hyper- 
plasias of  the  thyroid  are  less  common  than  in  those  countries — portions  of 
Switzerland,  certain  counties  in  England,  and  districts  in  India — where  goiter 
is  endemic.  By  far  the  largest  proportion  of  cases  seen  in  America  are  cir- 
cumscribed tumors  of  one  or  other  lateral  lobe,  and  of  these  the  cystic  variety 
is  notably  frequent. 

Simple  Hyperemia  of  the  Thyroid. — Simple  hyperemia  of  the  thyroid 
occurs  for  the  most  part  in  young  women  and  girls ;  is  associated  with  puberty, 
menstruation,  or  pregnancy.  The  gland  is  moderately  enlarged,  not  sufficiently 
to  cause  marked  deformity,  of  soft  and  normal  consistence.  In  some  cases  this 
condition  precedes  permanent  follicular  hypertrophy  of  the  gland  of  the  diffuse 

type.  The  individuals  thus 
affected  are  usually  young 
women.  The  entire  gland 
is  markedly  increased  in 
size  and  of  firm  consistence. 
The  surface  may  be  smooth, 
or  here  and  there  groups  of 
follicles  may  cause  rounded 
elevations  of  small  size  on 
the  surface.  One  or  more 
soft  nodular  prominences 
appearing  at  the  time  of 
puberty  in  a  gland  other- 
wise normal,  which  grow 
very  slowly  or  remain  sta- 
tionary and  do  not  reach  a 
size  larger  than  a  small 
hen's  es;g,  and  cause  no 
symptoms  other  than  slight 
deformity,  are  often  fetal 
adenomata  (Worrier's). 

Colloid  Goiter. — Colloid 
goiter  of  the  diffuse  type 
occurs  for  the  most  part  in 
women  during  middle  life. 
The  tumor  is  of  slow  growth, 
but  attains,  after  a  time,  a  large  size.  The  two  halves  of  the  gland  are  usually 
enlarged  unequally.     They  may  form  prominent  tumors,  each  as  large  as  a 


Fig.  208. — Cystic  Goiter. 
(Collection  of  Dr.  Charles  McBurney.) 


DISEASES    AND   TUMORS    OF   THE   THYROID    GLAND 


577 


man's  fist  or  larger.     The  consistence  is  rather  soft  and  doughy.     When  diffuse 
hypertrophy  affects  especially  the  blood-vessels,  the  entire  gland    is  enlarged, 
and  may  pulsate  distinctly  on  palpation.      There  may  be  a  vascular  murmur. 
The   tumor   can  be   diminished   in 
size  by  firm   compression,   but   en- 
larges  again  rapidly  as   the  blood 
reenters  the  vessels. 

Fibrous  Goiter. — Fibrous  goi- 
ter is  a  comparatively  rare  form. 
It  occurs  for  the  most  part  in  per- 
sons advanced  in  life,  and  is  char- 
acterized by  the  formation  of  nod- 
ules of  dense,  hard,  fibrous  tissue 
disseminated  through  the  substance 
of  the  gland.  The  individual  nod- 
ules may  be  as  small  as  a  pea  or 
occupy  an  entire  lateral  lobe  and 
form  a  mass  of  considerable  size. 
Calcareous  degeneration  in  the 
nodules  renders  them  as  hard  as 
bullets.  The  nodules  are  usually 
movable  one  on  the  other.  They 
may  project  from  the  surface  of 
the  gland  and  become  peduncu- 
lated. 

Cystic  Thyroid. — The  formation  of  cysts  has  already  been  described.  They 
may  form  in  a  gland  apparently  otherwise  normal  (a  very  common  form  in 
the  United  States),  or  in  combination  with  diffuse  hypertrophy  of  the  paren- 
chymatous or  fibrous  variety.  The  cysts  vary  greatly  in  size,  from  that  of  a 
pea  to  an  orange ;  in  some  cases  they  reach  an  enormous  size,  and  cysts  have 
been  removed  weighing  many  pounds.  They  may  be  single  or  multiple.  The 
diagnosis  is  easy  if  the  cyst  is  of  fair  size  and  not  too  deeply  placed.  They 
form  rounded,  smooth,  elastic,  fluctuating  prominences.  If  large,  superficial, 
and  filled  with  clear  fluid,  they  may  rarely  be  translucent.  If  small  and  deeply 
placed  in  the  gland,  and  especially  if  a  calcareous  deposit  has  taken  place  in 
the  cyst  wall,  the  diagnosis  may  be  difficult.  The  diagnosis  may  be  confirmed 
and  the  character  of  the  contents  of  the  cyst  may  be  determined  with  an 
aspirating  needle.  In  introducing  a  needle  into  the  thyroid  for  diagnostic 
purposes,  the  strictest  precautions  of  asepsis  should  be  observed.  The  needle 
should  be  fine.  The  danger  of  wounding  one  of  the  enlarged  and  thin-walled 
veins  of  a  thyroid  tumor  with  a  large  aspirating  needle  and  the  subsequent 
formation  of  an  annoying  or  even  serious  hematoma  is  not  remote.  Unless  the 
surgeon  is  prepared  to  operate  at  once,  it  is  better  to  omit  the  use  of  a  needle 
altogether.  The  diagnosis  of  accessory  thyroid  tumors  is  often  impossible.  If 
38 


Fig.  209. — Cystic  Goiter. 
(Collection  of  Dr.  Charles  McBurney.) 


578  THE   NECK 

the  tumor  is  still  connected  with  the  thyroid  by  a  pedicle  of  thyroid  or  fibrous 
tissue,  it  may  not  be  difficult,  The  presence  of  enlargement,  diffuse  or  cir- 
cumscribed, in  the  gland  itself  might  be  an  aid,  as  well  as  a  history  of  prolonged 
sojourn  in  a  goitrous  district.  Tumors  in  the  suprahyoid  region  and  in  the 
base  of  the  tongue  may  be  accessory  thyroids.  The  thyroid  may  surround  the 
trachea  as  a  congenital  condition.  The  tumor  may  cause  obstructive  symptoms 
of  a  serious  or  fatal  character  soon  after  birth,  or  if  the  thyroid  become? 
enlarged,  at  any  subsequent  tinie.  "  Movable  thyroid  tumors  "  are  wholly  or 
partly  detached  portions  of  thyroid  tissue  which  lie  in  front  of  the  trachea 
and  move  in  and  out  of  the  superior  orifice  of  the  thorax,  descending  with 
inspiration,  rising  with  expiration.  If  they  become  swollen,  inflamed,  or  cal- 
careous, and  thus  impacted  behind  the  sternum,  they  give  rise  to  serious  pres- 
sure symptoms  upon  the  trachea  and  innominate  vein. 

Malignant  Tumors  of  the  Thyroid. — Both  sarcoma  and  carcinoma  occur  in 
the  thyroid  gland  with  moderate  frequency,  notably  in  goitrous  regions  and  in 
thyroids  already  the  seat  of  benign  enlargements. 

Sarcoma. — Any  of  the  types  of  sarcoma  may  occur  in  the  thyroid.  Usually 
the  tumor  involves  one  lateral  lobe;  less  commonly  the  entire  gland  is  infil- 
trated. The  sarcomata  are  characterized  by  rapid  growth,  rather  early  perfora- 
tion of  the  gland  capsule  and  infiltration  of  the  surrounding  tissue,  and  serious 
pressure  symptoms  often  the  ultimate  cause  of  death.  Symptoms  referable 
to  pressure  upon  the  esophagus  are  more  frequent  and  more  marked  than  is 
the  case  with  benign  growths,  serious  obstruction  of  the  esophagus  being  com- 
mon from  malignant  infiltration  or  pressure,  rare  from  the  pressure  of  a 
benign  growth.  The  skin  is  rather  rarely  involved  and  destroyed  with  ulcera- 
tion, hemorrhage,  necrosis,  putrid  decomposition,  etc.  The  disease  usually 
occurs  in  early  adult  life.  So  long  as  the  capsule  remains  intact  the  tumor  is 
movable.  After  the  surrounding  tissues  are  invaded,  more  or  less  fixation 
occurs.  The  consistence  varies  with  the  type  of  sarcoma,  but  is  usually  rather 
soft  than  hard.     Metastases  occur,  notably  in  the  lungs  and  bones. 

Carcinoma  of  the  Thyroid. — Carcinoma  occurs  in  the  majority  of  cases 
in  advanced  life,  but  has  been  observed  in  young  persons.  Ordinary  alveolar 
carcinoma  of  the  soft  medullary  and  rapidly  progressive  type  is  the  rule. 
Scirrhus  also  occurs,  but  is  much  more  rare.  A  third  type,  commonly  known 
as  adeno-carcinoma  of  the  thyroid,  occurs  in  only  a  few  cases,  and  is  a  very 
interesting  tumor,  since,  although  it  cause  metastases,  it  does  not  infect  the 
lymph  glands,  and  in  most  instances  neither  the  thyroid  itself  nor  the  second- 
ary tumors  depart  in  histological  structure  from  the  normal  gland  tissue.  The 
thyroid  may  even  remain  normal  in  size  and  yet  metastatic  tumors  form,  which 
recur  after  removal.  The  secondary  tumors  occur  very  commonly  in  the  bones. 
The  metastatic  tumors  are  sometimes  solitary.  They  occur  notably  in  the  skull 
and  lower  jaw,  in  the  clavicle,  ribs,  and  other  long  bones.  The  growth  may 
be  very  slow,  so  that  years  elapse  before  the  tumor  reaches  a  considerable  size. 
Strangely  enough,  the  secondary  tumors  may  show  the  structure  of  alveolar 


DISEASES    AND   TUMORS    OF   THE    THYROID   GLAND  579 

carcinoma,  and  alveolar  carcinoma  <>f  the  thyroid  may  produce  metastases  re- 
sembling in  structure  the  normal  thyroid.  Clinically  the  metastases  in  the  bones 
resemble  sarcomata.  The  alveolar  carcinomata  of  the  thyroid  occur  more  often, 
as  stated,  in  advanced  life  and  in  goitrous  thyroids  rather  than  in  young  per- 
sons with  normal  glands.  The  tumor  usually  begins  as  a  nodule,  which  grows 
rather  rapidly  and  may  infiltrate  the  entire  gland ;  perforates  the  capsule  and 
infiltrates  the  surrounding  tissues ;  causes  infection  of  lymph  nodes  and  metas- 
tases. These  tumors  ordinarily  cause  early  and  grave  pressure.  Symptoms  are 
pain,  dyspnea,  dysphagia,  recurrent  laryngeal  and  sympathetic  paralysis,  pres- 
sure upon  the  veins  with  congestion,  edema,  etc. ;  but  it  is  astonishing  to  what 
a  large  size  a  carcinoma  of  the  thyroid  may  attain  and  yet  leave  the  patient 
fairly  comfortable,  notably,  if  while  the  tumor  grows  a  fibrous  capsule  con- 
tinues to  surround  it  at  least  in  part.  I  recall  such  a  case,  an  elderly  man 
with  an  enormous  thyroid  tumor  just  ready  to  perforate  the  skin  of  the  neck 
over  an  area  of  moderate  size,  and  evidently  malignant,  but  who  yet  was  in 
fair  general  health,  suffered  but  little  pain,  had  only  moderate  dyspnea  on 
exertion,  and  some  congestion  of  the  face.  He  desired  me  to  remove  the  tumor. 
Being  young,  inexperienced,  and  rash,  I  attempted  to  remove  the  growth,  but 
was  obliged  to  desist  on  account  of  bleeding.  At  the  autopsy,  which  was  made 
at  no  very  remote  date,  the  tumor  tissue  was  found  to  pass  into  the  thorax  and 
to  completely  surround  the  aorta.  Except  the  intrathoracic  part,  and  over  a 
rather  small  area  in  the  upper  part  of  the  neck,  the  very  large  tumor  was 
surrounded  by  a  fairly  thick  connective-tissue  capsule,  perforated,  however,  by 
numerous  large  vessels. 

Scirrhous  carcinoma  occurs  in  elderly  people,  and  is  much  less  common  than 
the  alveolar  form.  The  tumor  is  rarely  large,  is  characterized  by  stony  hard- 
ness, and  often  produces  marked  pressure  symptoms,  although  the  duration  of 
life  is  longer  than  in  the  alveolar  form.  On  section  the  tumor  shows  a  struc- 
ture of  firm  fibrous  tissue,  with  occasional  alveoli  containing  cells  in  a  condition 
of  fatty  degeneration,  and  granular  material.  At  the  advancing  border  the 
alveoli  with  strings  and  nests  of  epithelial  cells  are  more  numerous.  Here,  as 
elsewhere,  the  neighboring  tissues  are  slowly  but  continuously  invaded  with  the 
formation  of  dense  masses  and  strands  of  contracting  fibrous  tissue.  Often 
the  gland  is  diminished  rather  than  increased  in  size.  The  involvement  of  the 
lymph  nodes  greatly  aids  in  the  diagnosis. 

Diseases  of  the  Thymus  Gland. — -The  thymus  usually  undergoes  atrophy,  and 
is  normally  represented  at  birth  by  a  mass  of  fatty  tissue  lying  in  the  anterior 
mediastinum,  behind  the  sternum,  above  the  pericardium,  and  between  the  in- 
nominate and  left  common  carotid  arteries,  in  which,  however,  some  residue 
of  gland  tissue  has  been  demonstrated.  It  may  persist  in  adult  life,  but  is 
very  rarely  of  pathological  consequence  except  when  it  becomes  the  seat  of 
sarcoma. 

Status  lympkaticus. — The  chief  surgical  interest  in  the  organ  is  that 
in  the  so-called  "  status  lymphaticus  "  enlargement  of  the  thymus  is  associated 


580  THE   NECK 

with  general  hyperplasia  of  the  lymph  nodes,  congenital  narrowing  of  the  aorta 
and  of  the  entire  arterial  system.  The  condition  resembles  persistent  chronic 
chlorosis,  with  a  decided  feebleness  of  constitution,  such  that  these  individuals 
suffer  from  heart  and  respiratory  failure  of  a  serious  and  even  fatal  character 
from  slight  depressing  causes.  Injuries  and  operations  of  a  trifling  character 
and  the  administration  of  anesthetics  are  often  followed  by  death.  Death  may 
occur  suddenly  at  any  time  during  anesthesia,  with  the  symptoms  of  cyanosis 
or  paleness,  shallow  respiration,  dilated  pupils,  and  a  failing  heart  which  does 
not  readily  respond  to  stimulation,  or  the  death  may  be  delayed  for  some 
hours.  The  pulse  is  apt  to  be  rapid  during  and  after  the  anesthesia,  and  heart 
failure  comes  on  gradually  or  quickly,  with  coincident  respiratory  failure, 
unconsciousness,  and  death.  In  these  cases  the  thymus  is  regularly  found 
enlarged,  but  never  enlarged  enough  in  the  adult  cases  to  compress  the  trachea. 
The  lymph  nodes  are  moderately  enlarged  throughout  the  body.  The  aorta 
is  often  narrower  than  normal.     The  spleen  is  usually  somewhat  enlarged. 

The  diagnosis  of  the  status  lymphaticus  is  important  because  such  patients 
should  not  be  anesthetized  nor  operated  upon  if  it  is  possible  to  avoid  it.  The 
enlargement  of  the  thymus  and  the  narrowness  of  the  aorta  can  hardly  be 
made  out  during  life.  The  signs  which  would  lead  to  a  suspicion  of  the 
disease  are  palpable  lymph  nodes  in  regions  where  they  are  superficial ;  rarely 
the  mesenteric  glands  (Ewing),  a  flabby  and  anemic  habitus,  enlarged  tonsils, 
and  the  presence  of  adenoids ;  a  history  of  attacks  of  syncope  and  of  a  tendency 
to  dyspnea  and  respiratory  failure.  Apparent  smallness  of  the  principal  ar- 
teries. A  certain  proportion  of  the  cases  are  associated  with  exophthalmic 
goiter,  and  in  some  there  are  the  signs  of  rachitis  in  early  life. 

In  infants  and  children  a  few  cases  of  actual  compression  of  the  trachea 
by  an  enlarged  thymus  have  been  recorded,  producing  severe  dyspnea,  which 
has  in  several  instances  been  permanently  relieved  by  removing  a  portion  of 
the  gland,  pulling  the  remainder  up  into  the  neck  and  stitching  it  fast  to  the 
most  convenient  tissues,  thus  anchoring  it. 

Sarcoma  of  the  Thymus. — Sarcoma  of  the  thymus  is  very  rare.  The 
symptoms  are  those  of  a  tumor  in  the  mediastinum  compressing  the  viscera, 
causing  also  dullness  on  percussion.  A  fluoroscopic  examination  or  a  radio- 
graph might  establish  the  probable  diagnosis  of  a  mediastinal  tumor. 

THE   LARYNX   AND   TRACHEA 

Examination. — The  larynx  and  trachea  can  be  examined  by  external  inspec- 
tion and  palpation.  Some  data  in  cases  of  gross  lesions,  whether  due  to  injury 
or  disease,  may  thus  be  obtained.  The  larynx  may  be  examined  by  the  fore- 
finger inserted  into  the  mouth,  and  the  presence  of  foreign  bodies,  stenoses, 
tumors,  and  inflammatory  exudates  and  abscesses  may  thus  be  detected.  In- 
spection of  the  larynx  with  the  laryngoscopic  mirror  furnishes  more  informa- 
tion than  other  methods.     Properly  to  interpret  the  laryngoscopic  picture  of 


THE   LARYNX   AND    TRACHEA  581 

pathological  conditions  requires  much  training  and  experience.  The  technic 
of  the  examination  can  only  be  acquired  by  practice,  best  upon  the  normal 
subject.  The  student  may  indeed  practice  in  front  of  a  mirror  upon  his  own 
person.  In  this  manner  he  may  familiarize  himself  with  the  appearances  of 
the  healthy  larynx,  and  acquire  the  manual  dexterity  necessary  for  the  success- 
ful examination  of  cases  of  disease.  Endolaryngeal  operations  are  rarely 
attempted  except  by  specialists,  and  a  high  degree  of  skill,  only  to  be  acquired 
by  long  practice,  is  essential  for  their  performance.  For  the  practice  of  laryn- 
goscopy the  source  of  illumination  may  be  sunlight,  an  electric  bull's-eye  lamp, 
an  Argand  gas  burner  behind  a  bull's-eye  lens,  a  good  oil  lamp,  or  an  electric 
headlight  worn  upon  the  forehead ;  in  this  case  the  head  mirror  is  dispensed 
wTith.  A  centrally  perforated  concave  head  mirror  worn  upon  the  forehead, 
the  central  perforation  opposite  one  or  other  eye  of  the  operator,  is  commonly 
used  to  reflect  light  into  the  throat  and  illuminate  the  laryngoscopic  mirror. 
Laryngoscopic  mirrors  are  made  in  several  sizes ;  the  largest  mirror  should  be 
used  when  practicable.  A  laryngoscopic  mirror  is  now  made  with  a  small, 
cold  electric  light  attached.  I  have  found  it  convenient.  Cocainization  of 
the  pharynx  may  precede  the  examination  in  irritable  and  difficult  cases. 
In  studying  the  laryngoscopic  picture  of  pathological  conditions  it  is  to  be 
borne  in  mind  that  the  view  obtained  is  of  the  surface  merely ;  that  some 
portions  of  the  larynx  are  inaccessible  to  direct  vision,  and  that  many  of 
the  structures  are  seen  foreshortened.  The  extent  of  a  lesion  a  part  of 
which  only  can  be  seen  may  be  much  greater  than  appears.  It  is  impor- 
tant, therefore,  to  make  the  examination  in  the  most  painstaking  and  thor- 
ough manner,  and  to  bring  into  view  in  succession  every  part  of  the  larynx 
accessible  to  vision.  The  examination  is  conducted  as  follows :  The  room 
should  be  darkened;  the  patient  and  surgeon  sit  facing  one  another,  and  close 
together.  The  source  of  light  should  be  on  a  level  with  and  close  to  the  patient's 
ear.  If  the  surgeon  looks  through  the  head  mirror  with  his  left  eye,  the  light 
should  be  opposite  the  patient's  right  ear,  and  vice  versa.  The  patient  sits  with 
his  shoulders  thrown  a  little  forward  and  his  chin  slightly  elevated.  He  is  then 
directed  to  open  his  mouth  widely  and  to  thrust  out  his  tongue.  The  tongue 
is  then  held  with  a  piece  of  gauze  or  a  napkin  either  by  the  patient  or  by  the 
surgeon.  The  head  mirror  is  then  focused  and  rotated  until  the  light  is  con- 
centrated upon  the  uvula.  The  laryngoscopic  mirror  is  then  warmed  by  holding 
its  glass  surface  for  an  instant  over  a  lamp  until  a  film  of  moisture  forms  upon 
the  metal  surface  of  its  back  and  disappears.  Its  temperature  is  then  tested 
by  the  surgeon  upon  the  back  of  his  hand.  Holding  the  handle  of  the  mirror 
like  a  pen,  he  introduces  it  flatwise  into  the  patient's  mouth,  without  touching 
the  tongue,  until  it  rests  against  the  uvula,  which  is  pushed  a  little  upward 
and  backward,  but  not  into  contact  with  the  posterior  pharyngeal  wall;  the 
handle  of  the  instrument  is  then  elevated  a  little  and  approached  to  the  left 
corner  of  the  patient's  mouth.  The  larynx  will  then  come  into  view,  and  by 
slight  movements  of  the  mirror  the  various  parts  may  be  inspected.     The  front 


582  THE  NECK 

part  of  the  larynx,  the  epiglottis,  anterior  commissure,  etc.,  appear  at  the  top 
of  the  mirror ;  the  posterior  commissure,  arytenoids,  etc.,  at  the  bottom.  The 
patient  is  directed  to  pronounce  the  vowel  "  e,"  and  then  to  breathe  naturally, 
showing  the  vocal  cords  in  the  position  of  phonation  and  at  rest  respectively. 
In  the  first  instance  the  vocal  cords  are  seen  close  together  throughout,  and 
parallel  or  separated  posteriorly  by  a  small  triangular  space,  indicating  the 
ligamentous  and  cartilaginous  portions  of  the  cords  respectively.  During  nat- 
ural breathing  the  cords  are  separated,  leaving  3  triangular  spacer — the  rima 
glottidis — between.  During  deep  inspiration  they  separate  more  widely,  and 
one  can  see  several  rings  of  the  trachea,  or  sometimes  the  bifurcation  of  that 
tube.  The  parts  that  should  be  seen  are  the  true  and  false  vocal  cords,  the 
anterior  and  posterior  commissure,  the  ventricles  between  them,  the  arytenoids, 
the  aryteno-epiglottic  ligaments,  the  epiglottis,  the  base  of  the  tongue,  and 
sinus  pyriformis  and  glosso-epiglottic  ligaments.  The  movements  of  the  larynx 
should  be  carefully  observed.  The  normal  color  of  the  different  parts  can  be 
best  studied  by  direct  observation.  The  greatest  gentleness  and  steadiness  are 
essential  to  conduct  the  examination  properly.  Certain  obstacles  may  prevent 
a  satisfactory  examination :  1.  An  unusually  thick  tongue,  which  arches  upward 
and  obstructs  the  view ;  this  can  be  overcome  by  the  use  of  a  tongue  depressor. 
2.  An  intolerant  and  irritable  pharynx,  overcome  by  the  use  of  cocain.  3.  En- 
larged tonsils ;  cocain  and  the  use  of  a  rather  large  mirror  with  which  the 
tonsils  may  be  pressed  backward,  or  removal  of  the  tonsils.  4.  A  recurved 
and  overhanging  epiglottis ;  may  be  cocainized  and  held  forward  out  of  the 
way  with  a  soft  probe.  In  order  to  gain  a  better  view  of  the  posterior  com- 
missure and  the  posterior  surface  of  the  trachea  the  following  procedure  may 
be  adopted  (Killian)  :  The  patient  stands  with  his  head  bent  forward,  mouth 
widely  opened,  chin  resting  upon  the  sternum ;  the  tongue  is  drawn  strongly 
forward  out  of  the  mouth.  The  surgeon  sits  or  kneels  in  front  of  the  patient, 
and  causes  the  reflected  light  from  the  head  mirror  to  be  thrown  upward 
into  the  pharynx.  A  rather  large  laryngoscopic  mirror  is  used  in  the 
throat. 

It  is  possible  in  some  cases,  by  using  an  especially  constructed  tongue  de- 
pressor which  at  the  same  time  drags  the  base  of  the  tongue  forward,  to  look 
through  the  mouth  directly  into  the  larynx  when  the  head  is  extended  (Kir- 
stein).  Killian  has  made  use  of  a  straight  tube  to  look  into  the  trachea  under 
cocain  anesthesia.  The  head  being  fully  extended,  the  tube  is  passed  through 
the  larynx  into  the  trachea,  and  under  suitable  illumination  the  trachea,  and 
to  some  extent  the  bronchi,  may  be  examined.  A  similar  instrument,  resem- 
bling a  Kelly's  tube  for  examining  the  interior  of  the  female  bladder,  may  be 
introduced  through  a  tracheotomy  wound  (Coolidge,  New  York  Medical  Jour- 
nal, 1899),  and  the  trachea  and  bronchi  explored.  Coolidge  thus  successfully 
removed  a  foreign  body,  a  portion  of  a  rubber  tracheotomy  tube  in  the  right 
bronchus  through  a  speculum  half  au  inch  in  diameter  and  three  inches  in 
length.     By  holding  open  the  edges  of  a  tracheotomy  wound  a  small  mirror 


THE  LARYNX  AND  TRACHEA  583 

may  also  be  introduced  into  the  trachea,  and  the  larynx  may  be  viewed  from 
below  upward,  the  trachea  from  above  downward. 

Congenital  Defects  of  the  Larynx. — The  only  congenital  defect  of  the  larynx 
possessing  a  surgical  interest  is  itself  exceedingly  rare.  It  consists  of  a  mem- 
branous diaphragm  uniting  the  vocal  cords  to  a  variable  extent,  beginning  at 
the  anterior  commissure  and  extending  backward,  to  end  in  a  free  concave 
border.  If  the  membrane  unduly  narrows  the  orifice  of  the  larynx  it  will 
cause  more  or  less  marked  dyspnea. 

Laryngocele,  Tracheocele. — The  air-containing  tumors  connected  with  the 
larynx  and  trachea.  Wounds  of  the  larynx  and  trachea  are  commonly  at- 
tended by  subcutaneous  emphysema  more  or  less  extensive.  A  perforation  of 
the  trachea  from  within  by  ulceration  or  abscess  of  its  wall  would  doubtless 
cause  the  same.  An  abscess  of  the  surrounding  tissues  which  ruptured  into 
the  trachea  might  leave  behind  a  cavity  which  would  fill  with  air.  There 
occur  dilatations  of  the  ventricles  of  the  larynx,  either  congenital  or  acquired, 
which  protrude  through  the  thyro-hyoid  membrane,  and  present  outside  the 
larynx  either  in  the  middle  line  or  laterally.  They  are  reducible  tumors ;  a 
noise  may  be  heard  as  the  air  passes  in  and  out  of  the  sac.  They  increase 
in  size  on  coughing,  etc.,  and  are  resonant  on  percussion. 

Tracheocele — i.  e.,  sacs  containing  air  connected  with  the  trachea — have 
been  described,  resulting  from  dilatation  of  the  mucous  glands  of  the  trachea 
or  from  defective  development  of  the  cartilaginous  rings.  The  diagnosis  rests 
upon  the  recognition  of  an  elastic  reducible  tumor  connected  with  the  trachea, 
which  increases  suddenly  in  size  on  coughing,  crying,  sneezing,  etc. ;  the  reduc- 
tion or  inflation  of  the  tumor  may  be  accompanied  by  an  audible  sound.  On 
account  of  the  proximity  to  other  air-containing  cavities  (trachea,  lung),  a 
tympanitic  percussion  note  over  the  sac  is  not  an  entirely  reliable  diagnostic 
sign. 

Wounds  of  the  Trachea  and  Larynx. — Wounds  of  the  trachea  and  larynx 
have  already  been  described. 

Scalds,  Burns,  and  the  Action  of  Caustic  Fluids  on  the  Larynx. — These  in- 
juries occur  from  inhaling  flame,  steam,  or  other  hot  vapors,  and  from  drink- 
ing hot  or  caustic  liquids.  The  mucous  membrane  of  the  larynx  above  the 
level  of  the  vocal  cords  is  usually  the  seat  of  the  injury.  As  upon  the  skin, 
erythema,  vesication,  or  necrosis  may  follow,  according  to  the  degree  of  heat, 
etc.  There  are  always  evidences  of  similar  lesions  in  the  mouth  and  pharynx. 
The  important  symptoms  are  dyspnea,  pain  in  speaking  and  swallowing.  Later, 
inflammatory  complications  on  the  part  of  the  mucous  membrane  of  the  larynx 
may  necessitate  tracheotomy  many  days  after  the  injury.  In  the  presence  of 
a  corresponding  history  the  diagnosis  is  plain.  In  the  absence  of  such,  the 
inflammatory  lesions  might  be  mistaken  for  diphtheria. 

Foreign  Bodies  in  the  Air  Passages. — Foreign  bodies  gain  entrance  into  the 
air  passages  from  various  sources  and  in  various  ways.  Usually  such  bodies 
are  aspirated   directly  from  the  mouth,  by  a   sudden  inspiration  caused  by 


584  THE   NECK 

laughing,  crying,  speaking,  falling,  being  startled,  while  a  foreign  body  or 
portion  of  food  is  in  the  mouth.  Such  accidents  are  nearly  twice  as  frequent 
in  children  as  in  adults  on  account  of  the  common  practice  among  children 
of  placing  all  sorts  of  objects  in  the  mouth.  The  variety  of  objects  which  have 
been  thus  aspirated  is  endless;  among  the  most  common  are  beans,  peas,  pins, 
coins,  kernels  of  grain,  nutshells,  beads,  buttons,  etc.  Very  often  the  body 
is  taken  into  the  mouth  as  and  for  food.  It  may  then  consist  of  fragments  of 
chicken,  or  other  meat  bone,  or  a  fish  bone,  or  a  partly  chewed  portion  of  meat. 
Greedy  adults  may  also  attempt  to  swallow  a  piece  of  meat  so  large  that  it 
becomes  impacted  in  the  pharynx  or  upper  end  of  the  esophagus,  and  a  portion 
of  it  may  rest  upon  or  be  aspirated  into  the  larynx.  In  a  considerable  number 
of  cases  an  extracted  tooth  or  a  portion  of  a  tooth  has  entered  the  larynx. 
During  sleep  or  alcoholic  coma,  false  teeth,  a  portion  of  tobacco,  etc.,  may  be 
aspirated  into  the  larynx,  and  vomited  material  in  any  form  of  coma.  During 
anesthesia  vomited  material  or  pus  or  blood  may  enter  the  larynx  and  trachea 
in  quantity,  on  account  of  the  loss  of  reflex  excitability  of  the  mucous  mem- 
brane caused  by  the  anesthetic.  Occasionally  the  foreign  body  may  gain  access 
to  the  air  passages  through  a  wound — for  example,  a  bullet  or  a  portion  of  a 
tracheotomy  tube  which  breaks  off  and  falls  into  the*  trachea.  Further,  as  the 
result  of  pathological  processes,  a  portion  of  a  tumor  may  slough  off  and  fall 
into  the  larynx,  a  portion  of  tuberculous  bone  from  an  abscess  of  the  verte- 
bra?, or  a  caseous  bronchial  gland,  or  a  foreign  body  in  the  esophagus  may 
enter  the  trachea  or  a  bronchus  by  ulceration.  Living  animals  may  enter  the 
air  passages ;  leeches,  when  used  therapeutically  in  the  mouth,  or  when  taken 
into  the  mouth  in  dirty  drinking  water;  further,  flies  may  enter  the  open 
mouth,  and  partly  vomited  lumbricoid  worms  may  enter  the  larynx.  The 
symptoms  produced  by  the  entrance  of  foreign  bodies  into  the  air  passages 
depend  upon  the  size,  shape,  and  consistency  of  the  body ;  further,  upon  whether 
it  lodges  in  the  larynx  or  passes  into  the  trachea,  remains  free,  becomes  im- 
pacted, or  passes  into  a  bronchus.  If  the  body  is  aspirated  and  completely 
occludes  the  larynx,  the  patient  has  a  feeling  of  suffocation,  makes  violent 
efforts  to  inspire  air,  turns  blue  in  the  face,  and  if  unable  to  cough  up  the 
offending  object  and  adequate  aid  is  not  at  hand  dies  of  asphyxia  at  once.  If 
the  body  is  impacted  in  the  larynx,  but  does  not  completely  occlude  it,  the 
symptoms  are,  violent  spasmodic  cough,  dyspnea,  pain  in  the  larynx,  and  hoarse- 
ness or  aphonia,  usually  gagging  and  vomiting.  If  sufficient  space  remains  for 
breathing,  the  cough  and  dyspnea  may  subside  after  a  time,  to  recur  at  inter- 
vals. I  saw  a  man  who  had  a  ten-cent  silver  piece  impacted  transversely  in 
his  larynx  between  the  true  and  false  vocal  cords ;  when  seen  some  hours  after 
the  coin  had  lodged  he  had  aphonia,  some  pain  and  discomfort,  but  no  dysp- 
nea. A  small  smooth  foreign  body  may  enter  a  ventricle  of  the  larjmx  and 
cause  but  slight  discomfort,  remaining  indefinitely,  or  be  finally  coughed  out 
or  aspirated  into  the  trachea.  Hard  bodies  of  sharp  or  irregular  contour  may 
wound  the  mucous  membrane,   and  notably  the  vocal  cords.      If  allowed  to 


THE   LAKYNX   AND    TEACHEA 


585 


remain,  inflammatory  complications  occur.  The  pressure  of  the  body  may 
cause  ulceration,  which  may  extend  deeply  and  result  in  an  abscess  which 
burrows  outwardly  or  down  the  neck,  or  any  one  of  the  large  blood-vessels  of 
the  neck  may  be  perforated  with  fatal  bleeding.  More  commonly  inflam- 
matory swelling  of  the  mucous  membrane  of  the  larynx  causes  edema  glot- 


l& 


^/t\i\ 


\\^ 


Fig.  210. — Bronchoscope. 


tidis  and  dangerous  or  fatal  dyspnea.  Accompanying  pressure  necrosis  of  the 
laryngeal  mucous  membrane  there  will  be  cough  with  bloody  and  purulent 
expectoration. 

The  large  soft  masses,  such  as  pieces  of  meat  or  other  material,  either  taken 
into  the  mouth  or  vomited  during  anesthesia,  are  more  apt  to  cause  immediate 
asphyxia  than  are  small  hard  objects.     Vomited  material,  or  blood  or  pus  or 


Fig.  211. 


-Instruments  to  be  Used  with  the  Bronchoscope  for  the  Extracting  of  Foreign 
Bodies  from  the  Bronchi  and  Trachea. 


other  liquid  entering  the  trachea  in  large  quantity,  may  cause  immediate 
asphyxia,  or  gradually  increasing  dyspnea  and  cyanosis  with  death  from  car- 
bonic-acid poisoning  and  want  of  oxygen  after  some  hours.  Such  accidents 
occur  during  anesthesia  from  aspiration  of  vomited  material  or  blood  or  pus, 
occasionally  from  clumsy  efforts  on  the  part  of  unskillful  persons  to  wash  out 
the  stomach  of  unconscious  or  very  feeble  patients  too  weak  to  cough.  I  once 
saw  a  stomach-tube  introduced  through  the  larynx  of  a  patient  who  had  taken 


586  THE  NECK 

strychnin  with  suicidal  intent.  Water  was  poured  into  the  tube,  and  death 
occurred  from  asphyxia  in  a  moment.  The  trachea  and  bronchi  were  found 
full  of  water.  If  food,  blood,  or  pus  be  aspirated  in  quantity  not  sufficient  to 
cause  asphyxia,  the  material  finds  its  way  into  the  bronchi.  Septic  pneu- 
monia often  follows  after  some  days,  and  will  give  characteristic  physical  signs 
and  general  symptoms.  Hard  bodies  aspirated  into  the  trachea  cause  a  differ- 
ent train  of  symptoms,  according  as  they  remain  movable  or  become  impacted. 
When  the  body  falls  down  upon  the  bifurcation  of  the  trachea  a  violent  spasm 
of  coughing  is  excited  and  the  body  is  thrown  out  violently  against  the  larynx, 
causing  spasmodic  closure  of  the  glottis ;  as  it  falls  again  another  spasm  of 
coughing  occurs,  and  this  series  of  events  continues  either  until  the  body 
becomes  impacted  or  is  coughed  up  or  the  patient  chokes  to  death.  It  may  be 
possible  by  auscultation  to  hear  the  sounds  made  by  the  body  at  either  end 
of  its  excursions.  When  the  body  becomes  fixed,  and  does  not  entirely  occlude 
the  air  passages,  the  violent  symptoms  will  often  subside  completely.  There 
will  remain  a  fixed  pain  at  the  point  of  impaction  and  more  or  less  dyspnea. 
Owing  to  the  larger  size  and  direction  of  the  right  bronchus,  bodies  are  more 
apt  to  enter  it  than  the  left.  If  the  body  occludes  the  bronchus,  there  will  be 
absence  of  breathing  over  the  affected  lung  with  at  first  normal  resonance,  dimin- 
ished mobility  of  the  affected  side  of  the  chest  during  respiration,  and  according 
to  some  observers  diminished  vocal  fremitus,  together  with  increased  breathing 
over  the  other  lung.  If  the  body  has  entered  a  smaller  bronchus  and  occludes 
it,  these  signs  will  be  less  marked  and  limited  to  that  portion  of  lung  deprived 
of  air.  If  the  body  becomes  impacted  in  a  bronchus  and  does  not  completely 
occlude  it,  there  will  be  an  audible  whistling  sound  or  coarse  rale  at  the  point. 
Such  bodies  may  remain  quiescent  for  a  long  time  without  producing  serious 
symptoms,  and  may  even  become  encysted,  but  in  most  cases  they  set  up  ulcer- 
ation, severe  bronchitis,  localized  septic  pneumonia  or  abscess  of  the  lung,  with 
corresponding  physical  signs  and  symptoms.  In  these  cases  putrefactive 
changes  often  occur,  and  the  breath  and  sputum  acquire  a  foul  putrid  odor. 
The  lung  may  be  perforated  with  the  formation  of  localized  purulent  pleuritis 
or  empyema,  or  the  lung  may  become  adherent  to  the  chest  wall  and  the 
abscess  may  point  externally.  In  such  cases  the  foreign  body  may  be  found 
in  the  pus  when  the  abscess  is  incised. 

The  diagnosis  of  the  presence  of  a  foreign  body  in  the  air  passages  is  some- 
times easy,  often  difficult.  In  case  the  foreign  body  has  been  aspirated  from 
the  mouth,  a  positive  history  of  such  an  event  is  important;  in  children  it  can 
seldom  be  obtained.  It  often  happens  that  adults  actually  swallow  a  foreign 
body  which  scratches  the  pharynx  or  esophagus  as  it  goes  down.  The  sore 
sensation  left  behind  may  lead  them  to  believe  that  the  body  is  still  present, 
and  they  may  locate  their  sensations  in  the  larynx.  A  negative  physical  exami- 
nation, absence  of  dyspnea,  etc.,  and  the  subsequent  passage  of  the  body  per 
anum,  confirms  a  negative  diagnosis.  When  a  patient  aspirates  food  into  the 
larynx  during  anesthesia,  the  event  is  preceded  by  visible  contractions  of  the 


THE   LARYNX   AND    TRACHEA  587 

diaphragm,  usually  by  the  appearance  of  vomited  material  in  the  mouth,  by 
cessation  of  breathing  or  irregular  breathing,  cyanosis,  and,  if  asphyxia  occurs, 
dilated  pupils  and  death.  The  rapid  introduction  of  the  finger  into  the  back 
of  the  throat  (a  gag  having  been  used  to  open  the  mouth  and  avoid  injury  to 
the  finger)  will  usually  demonstrate  the  presence  of  vomited  material.  The 
presence  of  such  material  in  the  trachea  can  be  demonstrated  through  a  tracheot- 
omy wound  by  aspiration  through  a  soft  catheter.  In  cases  of  asphyxia  in 
conscious  persons,  the  presence  of  air  hunger,  cyanosis,  and  mental  anguish  are 
unmistakable.  The  foreign  body  can  sometimes  be  felt  by  a  finger  introduced 
into  the  back  of  the  throat.  In  parenthesis  I  might  add  that  in  these  cases, 
unless  the  body  is  removed  by  the  finger,  almost  instant  tracheotomy  offers  the 
only  hope  of  saving  life.  In  cases  less  urgent,  local  pain,  hoarseness,  or  aphonia 
would  lead  us  to  suppose  that  the  body  was  in  the  larynx,  where  a  laryngo- 
scopy examination  might  reveal  it.  If  the  signs  and  symptoms  indicated  a 
deeper  situation,  tracheotomy  and  one  of  the  methods  of  examination  already 
indicated  would  be  the  proper  diagnostic  measures  to  pursue,  and  that  without 
delay,  since  the  longer  the  body  is  allowed  to  remain  in  the  deeper  air  passages, 
the  greater  the  dangers  of  sepsis  and  irremediable  destruction  of  lung  tissue. 
I  refer  to  the  use  of  small  mirrors  in  the  tracheal  wound  or  inspection  of  the 
trachea  through  a  Kelly  tube,  or  better,  through  a  bronchoscope.  In  many 
cases,  if  the  body  is  not  impacted  it  will  appear  in  the  tracheal  wound  at  once, 
and  be  expelled,  or  may  be  extracted.  In  the  case  of  children,  a  foreign  body 
in  the  trachea  has  been  mistaken  for  croup.  The  paroxysms  of  coughing  and 
the  dyspnea  from  a  movable  foreign  body  are  apt  to  be  intermittent.  In  croup 
the  symptoms  tend  to  be  steadily  progressive.  Fever  does  not  serve  as  a  differ- 
ential point  because  a  foreign  body  in  the  trachea  or  in  a  bronchus  may  excite 
fever  in  a  day  or  two. 

Inflammatory  Diseases  of  the  Larynx. — Acute  and  chronic  catarrhal  laryn- 
gitis, as  well  as  spasmodic  croup,  are  scarcely  to  be  regarded  as  surgical  dis- 
eases, and  can  only  be  mentioned  here.  Laryngeal  diphtheria  caused  by  the 
Lofner  bacillus,  or  croupous  laryngitis  caused  by  streptococci,  are  of  surgical 
interest  only  so  far  as  the  laryngeal  obstruction  becomes  an  indication  for  intu- 
bation of  the  larynx  or  tracheotomy.  Laryngeal  obstruction  from  diphtheria 
is  observed  in  childhood  with  great  frequency.  Statistics  show  a  gradual  in- 
crease in  the  number  of  cases  from  birth  up  to  the  fourth  year  of  life,  after 
which  there  is  a  decline  up  to  the  age  of  fifteen.  In  older  persons  obstruction 
of  the  larynx  from  this  cause  is  comparatively  rare.  In  childhood  so  large 
a  proportion  of  cases  of  acute  laryngeal  obstruction  are  due  to  diphtheria  that 
failing  a  definite  history  to  the  contrary,  it  is  almost  safe  to  assume  a  diagnosis 
of  diphtheria  at  once.  In  a  large  proportion  of  cases  the  involvement  of  the 
larynx  is  an  extension  from  diphtheria  of  the  fauces  and  nose.  Less  com- 
monly the  larynx  is  primarily  affected,  rarely  the  trachea  and  bronchi.  The 
pathological  diagnosis  is  made  by  the  recognition  of  a  croupous  inflammation 
in  the  pharynx  on  inspection  or  in  the  larynx  by  laryngoscopy,  and  by  obtain- 


588  THE  NECK 

ing  smears  and  cultures  of  the  Loffler  bacillus  from  the  throat.  It  is  not 
always  necessary  to  obtain  the  bacilli  from  the  actual  seat  of  the  false  mem- 
brane; a  swab  swept  across  the  pharynx  and  tonsils  will  usually  give  positive 
results.  In  the  cases  of  secondary  involvement  of  the  larynx  the  symptoms  of 
respiratory  obstruction  will  be  preceded  by  the  local  and  constitutional  signs 
and  symptoms  of  nasopharyngeal  diphtheria.  When  the  diphtheria  is  secondary 
to  other  infectious  diseases — measles,  scarlet  fever,  etc. — the  symptoms  of 
these  diseases  will  have  been  present.  The  symptoms  referable  to  the  larynx 
usually  begin  with  cough  and  hoarseness.  The  cough  often  has  a  peculiar 
barking  quality  more  or  less  characteristic  of  laryngitis.  In  the  somewhat  rare 
cases  beginning  below  the  larynx  the  signs  and  symptoms  of  croupous  bron- 
chitis, cough,  expectoration,  dyspnea,  and  cyanosis  will  precede  the  symptoms 
referable  to  the  larynx.  Gradually  the  symptoms  of  obstruction  appear,  the 
cough  loses  its  resonant  character,  the  voice  becomes  more  and  more  feeble 
until  aphonia  is  established.  Transient  attacks  of  dyspnea  and  coughing  occur, 
sometimes  with  the  expulsion  of  a  portion  of  false  membrane  or  a  mass  of  muco- 
pus.  Gradually  respiration  becomes  labored.  Inspiration  is  prolonged  and 
accompanied  by  a  peculiar  and  characteristic  stridor.  The  accessory  muscles 
of  respiration  are  brought  more  and  more  into  play;  the  nostrils  dilate,  the 
muscles  of  the  neck  contract,  the  shoulders  are  elevated.  Expiration  is  also 
labored,  and  is  accompanied  by  an  audible  laryngeal  sound.  As  the  dyspnea 
increases  the  patient  is  unable  to  fill  the  thorax  with  air.  The  supraclavicular 
fossa?  show  depressions,  the  epigastrium  is  sunken,  the  intercostal  spaces  show 
grooves  in  thin  patients ;  attacks  of  violent  dyspnea  occur,  during  which  the  child 
becomes  cyanotic,  struggles  wildly  for  breath,  grasps  its  throat,  tries  to  scream, 
and  finally  falls  back  exhausted.  The  carbonic-acid  poisoning  gradually  in- 
creases, and  the  excitement  is  succeeded  by  somnolence  and  stupor.  The  res- 
pirations, at  first  rapid,  become  slower  than  normal,  the  pulse  more  and  more 
rapid  and  feeble,  the  nails  and  mucous  membranes  blue.  This  condition  ends 
in  death.  The  general  and  local  symptoms  are  so  characteristic  of  progressive 
laryngeal  dyspnea  that  they  are  to  be  recognized  at  a  glance.  The  picture  is 
painful  in  the  extreme.  After  the  condition  of  stupor  is  reached  an  inexperi- 
enced observer  might  think  the  disappearance  of  the  active  dyspnea  a  sign  of 
improvement.  In  adults  the  diagnosis  of  diphtheritic  laryngitis  can  be  made 
by  a  laryngoscopic  examination  and  concomitant  signs  and  symptoms.  In  chil- 
dren dyspnea  from  a  retropharyngeal  abscess  can  be  recognized  by  palpation 
and  inspection  of  the  pharynx.  Tumors  and  inflammatory  exudates  in  the 
substance  of  or  around  the  larynx  usually  give  definite  signs  and  symptoms. 
Spasmodic  croup  occurs  in  sharp  intermittent  attacks,  without  the  local  and 
general  symptoms  of  diphtheria. 

Edema  laryngis. — Local  trauma — mechanical,  thermal,  or  chemical — acute 
inflammations  of  many  kinds  in  the  tissues  of  the  larynx  or  in  the  vicinity 
(erysipelas),  and  ulcerative  processes  of  the  laryngeal  mucous  membrane,  may 
give  rise  to  inflammatory  edema  sufficient  to  close  the  laryngeal  orifice  and  cause 


THE   LARYNX   AND    TKACITEA  589 

dyspnea  or  asphyxia.  The  edema  of  cardiac  and  renal  disease  may  do  the 
same,  as  well  as  emphysema  of  the  lungs.  Further,  tumors  in  the  neck  and 
thorax,  causing  venous  obstruction,  notably  large  tumors  of  the  thyroid,  occa- 
sionally aneurism  of  the  aorta.  In  the  course  of  acute  infectious  diseases — 
typhoid  fever,  scarlatina,  small-pox — such  edema  may  occur.  The  swelling  of 
the  aryteno-epiglottidean  folds  of  mucous  membrane  is  largely  the  cause  of  the 
obstruction;  such  swelling  can  usually  be  felt  by  the  forefinger  introduced  into 
the  throat,  and  may  be  readily  seen  in  the  laryngoscopic  mirror.  In  some  cases 
the  swollen  epiglottis  may  hide  the  laryngeal  opening;  in  others  the  swollen 
ridges  formed  by  the  aryteno-epiglottidean  folds  will  be  readily  visible ;  in  other 
cases  of  inflammation  of  the  submucous  tissues  of  the  larvnx  the  swelling:  will 
lie  below  the  level  of  the  vocal  cords.  Some  of  these  cases  end  in  suppuration, 
and  it  may  be  possible  to  see  the  yellow  color  of  the  pus  beneath  the  thinned 
mucous  membrane.  The  peculiarity  and  interest  of  the  condition  lies  in  the 
fact  that  the  obstruction  may  occur  suddenly  and  reach  a  dangerous  degree 
in  a  very  short  time.  This  is  notably  the  case  when  moderate  degrees  of 
stenosis  exist  as  the  result  of  pressure  upon  the  larynx  and  trachea  by  tumors 
or  exudates ;  or  when  ulcerative  processes  or  tumors  exist  within  the  larynx 
itself;  a  moderate  swelling  of  the  mucous  membrane  may  then  be  sufficient  to 
cause  dangerous  obstruction. 

The  symptoms  of  laryngeal  obstruction  due  to  edema  laryngis  do  not  differ 
materially  from  those  described  under  diphtheria,  except  that  they  are  some- 
times very  acute  in  their  onset.  The  voice  is  changed,  becoming  hoarse  and 
raucous;  later,  weakened  or  lost.  The  dyspnea  is  at  first  inspiratory  merely; 
later,  expiration  may  also  be  interfered  with.  When  due  to  acute  inflammation 
or  to  the  presence  of  an  abscess  in  the  submucous  tissue  of  the  larynx  there 
will  be  pain  more  or  less  severe.  The  careful  surgeon  will  be  forewarned  and 
prepared  in  all  such  cases  to  afford  relief  by  tracheotomy  when  occasion  requires 
it.  The  condition  is  to  be  differentiated  from  the  dyspnea  symptomatic  of 
cardiac,  renal,  or  other  asthma,  by  the  absence  of  the  sounds  of  laryngeal 
obstruction,  and  the  negative  laryngoscopic  examination  in  these  latter  con- 
ditions. 

Perichondritis  of  the  Laryngeal  Cartilages. — Acute  purulent  inflammation 
of  the  perichondrium  of  the  cartilages  of  the  larynx  occurs  as  the  result  of 
infected  wounds  of  the  larynx ;  in  the  presence  of  impacted  foreign  bodies 
which  have  caused  local  ulceration,  secondary  to  ulcerative  processes  in  the 
larynx,  tubercular,  syphilitic,  carcinomatous,  or  other ;  as  a  primary  infection 
with  pyogenic  organisms,  the  point  of  invasion  being  unknown;  as  a  secondary 
or  metastatic  process  in  the  course  of  acute  infectious  diseases,  notably  typhoid 
fever,  the  acute  exanthemata,  and  in  the  course  of  generalized  septic  infections, 
pyemia,  septicemia.  The  arytenoids  and  the  cricoid,  rarely  the  thyroid  carti- 
lage, are  the  seat  of  the  inflammation.  The  process  resembles  a  purulent  peri- 
ostitis in  that  the  pus  accumulated  beneath  the  perichondrium  raises  this  layer 
from  the  surface  of  the  cartilage,  and  more  or  less  extensive  necrosis  of  the 


590  THE   KECK 

cartilage  follows.  The  abscess  may  rupture  into  the  larynx,  the  esophagus,  or 
pharynx,  or  into  the  soft  parts  of  the  neck  in  front  of  the  larynx,  or  posteriorly. 
The  pus  may  be  present  under  the  skin,  perforate  it,  leaving  a  fistula  leading 
to  dead  cartilage,  or  burrow  downward  in  the  neck.  Traumatic  and  septic 
cases  run  an  acute  course ;  those  due  to  tubercular,  syphilitic,  or  cancerous 
ulceration  of  the  larynx  are  chronic.  The  signs  and  symptoms  are :  Local 
pain  on  speaking  and  swallowing,  a  change  in  the  voice  and  dyspnea,  together 
with  the  discovery  of  a  localized  abscess  connected  with  the  larynx,  either 
externally  or  by  laryngoscopic  examination;  later,  the  discovery  of  exposed 
cartilage  with  a  probe,  after  the  abscess  has  ruptured  or  been  evacuated,  are  the 
data  from  which  a  diagnosis  is  to  be  made.  The  sequela?  of  the  condition  are 
sometimes  serious.  The  loss  of  portions  of  cartilage  may  lead  to  permanent 
changes  in  the  voice  or  to  immediate  dangerous  stenosis  of  the  larynx.  These 
patients  are  sometimes  obliged  to  wear  a  tracheotomy  tube  permanently. 

Tuberculosis  of  the  Larynx. — Tuberculosis  of  the  larynx  is  usually  secondary 
to  tuberculosis  of  the  lungs,  occasionally  primary  in  the  larynx  itself.  Sub- 
miliary  tubercles  or  more  diffuse  areas  of  tubercle  tissue  form  in  the  mucous 
membrane,  notably  in  the  posterior  part  of  the  larynx,  break  down,  and  create 
tubercular  ulcers  similar  to  other  tubercular  ulcers  of  the  mucous  membrane. 
The  symptoms  and  signs  are  local  pain  on  swallowing  and  speaking,  hoarseness, 
or  almost  complete  aphonia,  an  irritable  condition  of  the  larynx,  causing  a  fre- 
quent painful  cough,  and  a  muco-purulent  expectoration.  Recognition  of  infil- 
trations and  tubercular  ulcerations  in  the  larynx,  and  the  presence  of  tubercle 
bacilli  in  the  sputum,  or  in  the  discharges  from  the  ulcerating  surfaces,  estab- 
lishes the  diagnosis.  A  unilateral  involvement  of  the  larynx  and  extreme 
pain  on  swallowing  both  favor  the  diagnosis  of  tuberculosis. 

Syphilis  of  the  Larynx. — The  larynx  is  affected  in  a  pretty  large  proportion 
of  syphilitics.  In  the  early  secondary  stage  the  general  catarrhal  and  ery- 
thematous lesions  of  the  throat  may  affect  the  larynx  also;  later,  mucous  pap- 
ules in  the  form  of  flat  condylomata  may  occur,  and,  untreated,  may  cause 
stenosis  and  dyspnea.  The  tertiary  lesions  consist  of  gummata  or  of  diffuse 
infiltrations  of  the  tissues  of  the  larynx.  The  gummata  break  down,  forming 
crateriform  ulcers  with  a  red  border  and  a  base  of  characteristic  gummy  mate- 
rial. The  diffuse  infiltrations  lead  especially  to  cicatricial  contractions  and 
functional  disturbances  of  the  larynx,  sometimes  to  stenosis.  As  already  noted, 
necrosis  of  the  cartilages  may  occur.  The  diagnosis  depends  in  any  case  upon 
a  syphilitic  history,  the  presence  of  other  manifestations,  the  improvement 
produced  by  iodid  of  potassium,  the  appearance  of  the  ulcers,  absence  of  involve- 
ment of  the  lymph  nodes  in  tertiary  lesions,  even  though  of  long  duration. 
Syphilitic  gummata  are  more  apt  to  involve  the  front  part  of  the  larynx  and 
epiglottis.     Tuberculosis,  as  stated,  the  posterior  part. 

Fistula  and  Chronic  Stenoses. — It  is  to  be  noted  that  any  of  the  suppurative 
and  ulcerative  lesions  of  the  larynx,  whether  due  to  pyogenic,  tubercular,  or 
syphilitic  infection,  may  be  followed  by  a  fistula  of  the  larynx  opening  upon  the 


THE   LARYNX   AND   TRACHEA  591 

skin  of  the  neck ;  or  to  chronic  stenosis  due  to  cicatricial  contraction.  In  rare 
cases  a  necrotic  or  ulcerative  process  may  lead  to  fistulous  communication  be- 
tween the  trachea  and  the  esophagus.  The  symptoms  of  this  condition  are  due 
to  the  entrance  of  solids  and  liquids  into  the  trachea  during  the  act  of  swal- 
lowing. The  patients  choke  and  cough  in  a  manner  similar  to  that  which  we 
all  suffer  from  when  we  have  "  swallowed  the  wrong  way."  The  diagnosis 
may  he  confirmed  by  passing  a  stomach-tube  down  the  esophagus ;  so  long  as 
the  orifice  of  the  stomach-tube  remains  above  the  fistulous  opening  a  stream  of 
air  will  issue  from  the  external  orifice  of  the  tube  during  forced  expiration. 
The  diagnosis  of  the  chronic  stenoses  of  the  air  passages  is  generally  self-evi- 
dent from  the  history,  the  condition  of  chronic  dyspnea,  and  often  from  the 
presence  of  scars  and  irregularities  in  the  contour  of  the  larynx  and  trachea, 
and  from  the  laryngoscopic  examination. 

Benign  Tumors  of  the  Larynx. — The  commonest  benign  tumors  of  the  larynx 
are  papilloma  and  fibroma.  Chondroma  myoma,  lipoma,  adenoma,  cysts,  and 
angioma  have  also  been  observed. 

Papilloma. — The  papillomata  of  the  larynx  form  wartlike  excrescences 
having  a  cauliflower  surface,  resembling  in  conformation  the  acuminate  warts 
of  the  prepuce,  etc.  They  are  sessile  or  pedunculated  tumors,  single  or  mul- 
tiple ;  situated  on  the  true  or  false  vocal  cords  more  often  than  elsewhere,  some- 
times in  the  ventricles  or  on  the  epiglottis.  They  may  be  scattered  diffusely  over 
the  mucous  membrane  of  the  larynx.  They  occur  more  often  during  the  first 
three  decades  of  life  than  later ;  after  the  age  of  forty  years  they  are  apt  to  be 
the  forerunners  of  cancer.  The  symptoms  produced  vary  with  the  size  and 
situation  of  the  tumors.  Hoarseness  or  loss  of  voice,  a  sensation  of  irritation, 
"  as  though  a  foreign  body  were  in  the  larynx,"  cough,  occasionally  dyspnea — 
if  the  tumors  are  numerous  or  large — are  complained  of.  Laryngoscopic  exami- 
nation renders  the  diagnosis  plain.  It  is  to  be  borne  in  mind  that  the  removal 
of  the  tumors,  if  they  grow  from  the  vocal  cords,  may  leave  a  permanent  change 
in  the  voice,  and  that  recurrences  and  cancerous  degeneration  are  not  uncommon. 

Fibroma  and  Chondroma. — Fibroma  occurs  on  the  vocal  cords,  usually  near 
the  anterior  commissure.  Nearly  all  the  cases  have  occurred  in  men.  The 
tumors  are  covered  by  mucous  membrane,  normal  or  congested  in  appearance. 
They  are  usually  solitary,  and  rarely  grow  to  a  large  size — from  the  size  of  a 
pea  to  that  of  a  small  olive  being  the  ordinary  limits.  They  are  at  first  sessile 
tumors  of  even,  smooth  surface;  later  they  may  become  pedunculated  and  of 
uneven  contour.  They  vary  in  consistence  from  firm  and  hard  to  soft  and 
gelatinous  (from  myxomatous  changes).  Like  other  fibromata  their  growth 
is  slow.  True  myxoma  is  of  doubtful  occurrence.  The  symptoms  of  fibroma 
are  similar  to  those  of  papilloma — change  of  voice,  etc.  It  is  possible  for  a 
pedunculated  tumor  to  fall  into  the  rima  glottidis  from  time  to  time,  so  that 
the  voice  may  be  at  one  moment  normal  and  at  the  next  hoarse  or  lost.  In 
children,  especially,  dyspnea  in  attacks  may  occur  from  time  to  time..  The 
laryngoscopic  examination  is  all-important  for  the  diagnosis.     Chondroma. — A 


592  THE  NECK 

small  number  of  cases  only  have  been  observed.  The  tumors  are  composed  of 
hyaline  cartilage,  and  grow  from  the  surface  of  the  cricoid,  less  often  from 
the  thyroid  and  epiglottis,  in  one  or  two  cases  from  the  arytenoid  cartilages. 
The  diagnosis  must  be  made  from  the  hard  consistence,  the  connection  with  a 
cartilage,  and  the  slow  growth. 

Malignant  Tumors  of  the  Larynx. — Carcinoma  is  the  common  form,  sarcoma 
being  relatively  rare.  The  relative  frequency  of  the  two  conditions  is  about 
one  to  twelve.  Sarcoma  is  most  frequent  in  the  fourth,  fifth,  and  sixth  decades 
of  life.  The  seat  of  the  tumor  is  most  often  the  vocal  cords  and  the  epiglottis. 
On  these  situations  the  tumor  is  usually  of  the  spindle-celled  type.  In  the  other 
portions  of  the  larynx  there  occur,  less  commonly,  but  of  far  greater  malig- 
nancy, the  small  round-celled  and  alveolar  forms  (Bergeat).  The  spindle- 
celled  sarcomata  form  slowly  growing  nodular  tumors,  usually  sessile.  They 
show  no  very  marked  tendency  to  infiltrate  the  surrounding  tissues.  They  are 
of  firm  consistence,  are  usually  covered  by  fairly  normal  mucous  membrane, 
and  rarely  ulcerate  except  when  subjected  to  mechanical  irritation.  The  dif- 
ferential diagnosis  from  fibroma  is  scarcely  possible  except  by  a  microscopic 
examination.  The  round-celled  and  alveolar  forms  originate  in  other  parts 
of  the  larynx,  in  the  ventricles,  in  the  sinus  pyriformis,  and  below  the  vocal 
cords.  They  tend  to  grow  rapidly,  to  infiltrate  the  surrounding  soft  parts;  the 
cartilages  usually  remain  free,  although  destruction  of  cartilages  has  been 
noted  in  alveolar  sarcoma.  They  rarely  ulcerate,  affect  the  lymph  nodes  late 
in  the  disease,  if  at  all,  and  are  said  not  to  spread  upward  above  the  larynx 
involving  the  pharynx,  as  is  often  the  case  with  carcinoma.  In  spite  of  these 
characters,  however,  a  differential  diagnosis  from  carcinoma  is  not  always  pos- 
sible without  a  microscopic  examination.  The  clinical  symptoms  of  a  rapidly 
growing  tumor  causing  symptoms  referable  to  obstruction  of  the  larynx  are 
present. 

Carcinoma  of  the  Larynx. — Carcinoma  of  the  larynx  occurs  after  the  age 
of  forty  years  in  more  than  eighty  per  cent  of  all  cases ;  the  disease  is  much 
more  frequent  in  men  than  in  women;  excessive  smoking  and  drinking  are 
believed  to  favor  its  occurrence.  The  flat  epithelial  type  of  cancer  is  the  com- 
mon form,  cylinder-celled  or  adenocarcinomata  are  more  rare.  The  tumor 
may  originate  in  any  part  of  the  epithelial  lining  of  the  larynx.  In  certain 
cases  the  larynx  is  invaded  by  continuity  of  structure  from  primary  cancer  of 
the  tongue  and  pharynx.  The  disease  is  limited  to  one  side  of  the  larynx  in 
more  than  half  the  cases.  The  original  seat  of  the  disease,  according  to  the 
statistics  of  Sendziak,  who  tabulated  273  cases,  was  the  vocal  cords  in  107 
cases;  false  vocal  cords,  23  cases;  interarytenoid  folds,  15;  ventricles,  7;  below 
the  glottis,  7 ;  the  anterior  and  posterior  surfaces  of  the  posterior  wall  of  the 
larynx,  33;  epiglottis,  24;  pharyngeal  surface  of  the  posterior  wall  of  the 
larynx,  18;  aryepiglottic  folds,  13;  sinus  pyriformis,  7. 

The  disease  begins  as  a  flat  infiltration  of  the  tissues,  or  as  a  prominence 
with  a  broad,  firm  base,  in  either  case  surrounded  by  a  hyperemia  border.     The 


THE    LARYNX    AND    TRACHEA  593 

elevation  may  have  a  smooth,  nodular,  or  warty  surface,  and  may  be  covered 
by  epithelium  or  excoriated.  The  resemblance  to  an  ordinary  papilloma  may 
be  exact.  During  this  stage  the  spread  of  the  growth  may  be  slow  for  many 
months,  and  a  diagnosis,  although  difficult,  is  most  desirable,  since  operative 
removal  may  result  in  cure.  The  symptoms  at  this  stage  vary  witli  the  seat 
of  the  growth.  When  the  tumor  arises  within  the  cavity  of  the  larynx  and 
involves  a  vocal  cord,  primarily  or  by  extension,  or  if  the  movements  of  the 
cord  are  interfered  with,  by  fixation  of  an  arytenoid  cartilage  or  by  infiltration 
of  a  nerve  or  muscle ;  gradually  increasing  hoarseness  is  the  first  symptom 
noticed.  In  the  early  stages  of  these  intralaryngeal  growths  fixation  or  partial 
paralysis  of  one  vocal  cord  is  regarded  as  suspicious  of  cancer  (Semon).  If, 
on  the  other  hand,  the  epiglottis,  the  pharyngeal  surface  of  the  larynx,  or  other 
part  not  immediately  connected  with  the  mechanism  producing  vocal  sounds, 
is  the  primary  seat  of  the  disease,  pain  on  swallowing  will  be  first  noticed. 
In  making  a  diagnosis  at  this  stage  the  laryngoscopic  picture  is  most  impor- 
tant. As  was  pointed  out  in  another  place,  the  disease  is  usually  more  exten- 
sive than  the  picture  would  indicate.  In  cases  of  doubt,  examination  for 
tubercle  bacilli  in  the  sputum  and  of  scrapings  from  a  raw  surface,  if  such  there 
be,  inquiry  as  to  a  syphilitic  history,  the  administration  of  iodid  of  potassium, 
and,  finally,  the  removal  of  a  portion  of  the  growth  by  snare,  forceps,  etc., 
or  through  a  subhyoid  pharyngotomy,  or  better  by  median  fissure  of  the  thyroid 
cartilage,  and  microscopic  study  of  the  tumor  tissue,  are  the  means  whereby  a 
positive  diagnosis  may  be  reached. 

The  further  progress  of  the  disease  is  characterized  by  progressive  infiltra- 
tion of  the  surrounding  tissues.  The  original  growth  soon  loses  its  sharply 
marked  borders.  In  some  cases  the  infiltration  advances  along  the  surface 
chiefly,  in  others  more  into  the  deeper  tissues.  Ulceration  occurs  early  after 
the  process  has  assumed  an  active  character;  the  borders  of  the  ulcer  are  ele- 
vated and  hard ;  the  base  may  be  necrotic,  uneven,  and  granular,  or  from  it 
there  may  sprout  papillary  outgrowths  of  considerable  size.  Thus,  in  some 
cases  the  destructive  action  is  most  marked,  in  others  tumor  masses  of  consid- 
erable size  are  formed.  Invasion  and  destruction  of  cartilages  may  occur  or 
suppurative  perichondritis  and  necrosis.  Secondary  involvements  of  lymph 
nodes  occur  late  or  may  be  absent.  The  glands  under  the  sterno-mastoid  just 
below  the  angle  of  the  jaw  are  often  first  affected,  and  extension  of  the  disease 
outside  the  larynx  may  be  followed  by  enlargement  of  the  glands  in  the  sub- 
maxillary triangle.  The  symptoms,  as  the  disease  progresses,  are  increasing 
hoarseness  and  in  many  cases  dyspnea,  which  gradually  or  suddenly  assumes  a 
dangerous  character  and  may  occur  in  attacks  dependent  upon  inflammatory 
edema  of  the  mucous  membrane;  such  attacks  may  be  fatal.  The  stenosis 
produced  by  the  growth  of  tumor  tissue  may  be  marked,  but  is  sometimes  lim- 
ited by  sloughing.  There  is  a  cough  with  a  foul,  putrid  expectoration,  some- 
times blood-stained ;  bleeding  from  the  ulcerated  surfaces,  slight  or  severe ;  pain 

caused  by  speaking,  swallowing,  or  coughing ;  later  spontaneous  pain  of  a  severe 
39 


594  THE   NECK 

neuralgic  character  radiating  to  the  ear.  In  many  cases  no  external  palpable 
tumor  is  found,  nor  are  metastases  in  distant  organs  at  all  common.  As  the 
pain  and  difficulty  in  swallowing  increase,  the  patient's  nutrition  begins  to 
suffer.  Death  occurs  after  a  duration  of  rarely  longer  than  two  years,  from 
septic  pneumonia,  malnutrition   and  exhaustion,   or   asphyxia. 

Tumors  of  the  Trachea. — Fibroma,  lipoma,  sarcoma,  and  carcinoma  of  the 
trachea  have  been  observed.  The  carcinomata  are  more  often  caused  by  the 
extension  of  carcinoma  from  neighboring  organs  than  primary  in  the  trachea 
itself.  When  primary  they  occur  for  the  most  part  in  the  upper  portion  of 
the  trachea.  The  symptoms  of  tumors  of  the  trachea  are  chiefly  caused  by 
stenosis — i.  e.,  tracheal  dyspnea.  The  diagnosis  can  sometimes  be  made  by 
the  laryngoscope,  sometimes  through  a  Kelly  tube  passed  through  a  tracheot- 
omy wound  or  in  one  of  the  other  ways  mentioned  in  the  beginning  of  this 
chapter. 


CHAPTEE    XX 

THE  ESOPHAGUS 
TOPOGRAPHY   OF   THE   ESOPHAGUS 

The  esophagus  extends  from  the  pharynx  at  the  upper  border  of  the  cricoid 
cartilage  to  the  cardia  of  the  stomach.  It  is  between  nine  and  ten  inches  in 
length,  and  begins  opposite  the  intervertebral  disc,  between  the  fifth  and  sixth 
cervical  vertebra,  and  ends  opposite  the  body  of  the  tenth  dorsal  vertebra.  The 
tube  is  nearly  vertical,  but  exhibits  slight  curvatures  in  two  planes :  an  antero- 
posterior curvature  corresponding  to  the  anterior  surface  of  the  bodies  of  the 
vertebra?,  convex  forward  in  the  neck,  concave  forward  in  the  dorsal  region. 
Two  lateral  curvatures ;  beginning  above  in  the  median  line,  it  deviates  slightly 
to  the  left  as  far  as  the  root  of  the  neck,  where  it  is  about  one  half  inch  to 
the  left;  returns  again  to  the  middle  line  as  it  descends  in  the  mediastinum; 
where  it  again  bends  to  the  left  as  it  passes  forward  to  penetrate  the  diaphragm. 
The  caliber  of  the  tube  is  about  three  fourths  of  an  inch,  except  at  three  con- 
stricted points — opposite  the  cricoid,  opposite  the  left  bronchus,  at  the  place 
where  it  passes  through  the  diaphragm.  In  these  situations  its  diameter  is 
about  one  half  inch.  The  tube,  however,  admits  of  considerable  further  dis- 
tention without  injury.  When  empty  the  lumen  is  commonly  represented  by 
a  transverse  slit,  or  occasionally  by  a  stellate  orifice.  The  distance  from  the 
incisor  teeth  to  the  stomach  is  from  fifteen  to  fifteen  and  three  quarter  inches. 
From  the  incisor  teeth  to  the  point  of  bifurcation  of  the  trachea  or  to  the  left 
bronchus  is  about  nine  inches.  The  distance  from  the  cricoid  cartilage  to  the 
bifurcation  of  the  trachea  is  about  four  inches;  from  the  bifurcation  to  the 
cardia  of  the  stomach  about  six  inches ;  from  the  teeth  to  the  beginning  of 
the  esophagus  about  six  inches. 

RELATIONS   OF  THE   ESOPHAGUS 

Except  at  the  lower  end,  the  esophagus  is  surrounded  by  a  loosely  meshed 
layer  of  connective  tissue ;  it  is  therefore  somewhat  movable,  and  its  curves 
can  be  eliminated  during  the  introduction  of  a  straight  instrument.  "  It  is  hi 
relation  in  the  neck  in  front  with  the  trachea ;  in  the  lower  part  of  the  neck 
with  the  thyroid  gland  and  the  thoracic  duct,  where  it  projects  to  the  left  side. 
Behind  it  rests  upon  the  vertebral  column  and  longus  colli  muscle.     On  each 

595 


596 


THE   ESOPHAGUS 


side  it  is  in  relation  with  the  common  carotid  arteries,  especially  the  left,  and 
part  of  the  lateral  lobes  of  the  thyroid  gland ;  the  recurrent  laryngeal  nerves 
ascend  between  it  and  the  trachea.  In  the  thorax  it  is  at  first  situated  a  little 
to  the  left  of  the  median  line.  It  then  passes  behind  the  left  side  of  the  aortic 
arch,  and  descends  in  the  posterior  mediastinum,  along  the  right  side  of  the 
aorta,  nearly  to  the  diaphragm,  where  it  passes  in  front  and  a  little  to  the 
left  of  the  artery,  previous  to  entering  the  abdomen.  It  is  in  relation  in 
front  with  the  trachea,  the  arch  of  the  aorta,  left  carotid,  left  subclavian  arte- 
ries, the  left  bronchus,  and  the  posterior  surface  of  the  pericardium;  behind 
it  rests  upon  the  vertebral  column,  the  longus  colli  and  the  intercostal  vessels, 
and  below,  near  the  diaphragm,  upon  the  front  of  the  aorta  ;.  laterally  it  is 
covered  by  the  pleura? ;  the  vena  azygos  major  lies  on  the  right  and  the  de- 
scending aorta  on  the  left  side.  The  pnenmogastric  nerves  descend  in  close 
contact  with  it,  the  right  nerve  passing  down  behind  the  left  nerve  in  front 
of  it."     (Gray.) 

METHODS   OF   EXAMINING  THE   ESOPHAGUS 

The  various  methods  of  examining  the  esophagus  for  diagnostic  purposes 
are:  I.  The  examination  with  bougies  or  other  similar  instruments.  II.  Pal- 
pation. III.  Auscultation.  TV.  Percussion.  V.  Direct  inspection  through 
the  esophagoscope.     VI.  X-ray  examination. 

I.  Examination  with  Bougies,  etc. — The  bougies,  stomach-tubes,  probangs, 
coin-catchers,  and  other  similar  instruments  introduced  into  the  esophagus  for 
diagnostic  purposes  are  made  of  some  flexible  material  and  of  various  shapes 
and  sizes.  The  solid  bougies  are  made  of  a  silk  or  cotton  fabric,  impregnated 
and  coated  with  a  varnish,  which  is  hard  and  rigid  when  cold  but  becomes  soft 
and  pliable  when  warmed.  The  bougies  are  cylindrical,  and  are  made  in 
graduated  sizes.     Before  their  introduction  they  are  dipped  in  hot  water,  when 


G-  TIEMANN  &  Co. 


Fig.  212. — Coin-Catcher  and  Sponge  Probang  for  Extracting  Foreign  Bodies 

from  the  Esophagus. 


they  may  be  bent  to  any  desired  curve.  Such  bougies  are  also  made  hollow 
with  a  terminal  central  opening  or  a  lateral  eye  like  a  catheter.  For  easier 
engagement  in  a  stricture,  or  for  the  detection  of  the  same,  these  bougies  are 
sometimes  made  with  a  tapering,  rounded  point  or  with  a  pear-shaped  or 
olivary  extremity.     Olivary  bougies  are  also  made  with  a  shaft  of  whalebone 


METHODS    OF   EXAMINING   THE   ESOPHAGUS 


597 


or  metal,  graduated  in  centimeters  or  inches,  ending  in  a  metal  tip  with  a 
screw  thread,  to  which  may  be  attached  olivary  bodies  composed  of  ivory,  hard 
rubber,  or  metal  of  graduated  sizes.  A  slender,  flexible  guide  may  be  substi- 
tuted in  cases  of  narrow  stricture.  For  passing  very  narrow  strictures  it  is 
sometimes  necessary  to  use  filiform  bougies  composed  of  whalebone  or  silk.  In 
certain  cases  a  large,  hollow  bougie  with  a  terminal  opening  is  introduced  as 
far  as  the  stricture,  and  the  slender  guides  are  passed  inside  of  it  one  after 
another,  when  one  of  these  may  often  find  and  engage  in  the  orifice  of  the 
narrowed  portion  of  the  canal. 

A  convenient  method  of  passing  strictures  of  the  esophagus  was  devised 
by  Dunham.     He  causes  the  patient  to  swallow  water,  and  at  the  same  time 


|g6ag5B5B  /j,i  S55BBBB 


Fig.  213. — Spring  Forceps  for  Seizing  Foreign  Bodies  in  the  Esophagus. 

a  thread  or  slender  cord ;  the  water  carries  the  thread  through  the  stricture  into 
the  stomach.  The  thread  may  be  used  to  pull  larger  cords  or  instruments  into 
the  stomach  through  a  gastrostomy  wound,  or  may  be  used  to  enlarge  the 
stricture.  (See  works  on  Surgery  of  Stomach  and  Esophagus.)  Soft-rubber 
stomach-tubes  of  graduated  sizes,  usually  made  with  a  terminal  or  a  lateral  eye 
or  both,  are  useful  for  diagnostic  purposes  as  well  as  for  feeding  persons 
unable  to  swallow — lunatics,  unconscious  persons,  etc.  Such  tubes  are  also 
used  to  empty  and  cleanse  the  stomach,  and  for  various  therapeutic  and  diag- 
nostic purposes  some  of  which  will  be  noted  in  other  places.     The  coin-catcher, 


Fig.  214.— Graduated  Bulbous  Bougies  for  Detecting  Strictures  of  the  Esophagus. 

the  sponge  and  bristle  probangs,  are  therapeutic  rather  than  diagnostic  instru- 
ments, and  need  no  description  here.  They  may  be  used  also  for  the  detection 
of  foreign  bodies. 

The  introduction  of  bougies,  etc.,  into  the  esophagus  should  be  accomplished 
with  extreme  gentleness  lest  injury  be  done  to  the  esophagus  or  surrounding 
structures ;  this  caution  is  especially  true  when  stricture  of  the  esophagus  is 
present  from  any  cause — notably  from  malignant  or  inflammatory  disease,  or 
when  a  sharp,  hard  foreign  body  is  impacted  in  the  gullet.  A  false  passage 
may  easily  be  made,  to  be  followed  by  extravasation  of  septic  material  into 
the  surrounding  tissues  and   dangerous  or  fatal  suppurative  or  phlegmonous 


598  THE   ESOPHAGUS 

inflammation  in  the  neck,  mediastinum,  pleura,  or  pericardium.  The  great 
vessels  in  contact  with  the  esophagus  may  also  be  wounded  by  the  instrument 
itself,  or  by  undue  pressure  upon  a  foreign  body,  in  the  effort  to  extract  it 
or  push  it  into  the  stomach.  Before  introducing  an  instrument  into  the 
esophagus  in  cases  presenting  symptoms  of  chronic  obstruction,  it  is  wise, 
if  the  patient  be  no  longer  young,  to  examine  the  thorax  for  the  signs  of 
aneurism  of  the  aorta.  The  introduction  of  esophageal  bougies  in  cases 
of  aneurism  has  been  followed  by  rupture  and  fatal  bleeding  in  a  number  of 
instances. 

Method  of  Introducing  Flexible  Instruments  into  the  Esophagus. — The 
method  of  introducing  flexible  instruments  into  the  esophagus  is  as  follows: 
The  patient  sits,  the  head  inclined  slightly  forward,  thus  tending  to  separate  the 
larynx  a  little  from  the  posterior  pharyngeal  wall  and  to  avoid  the  possibility  of 
the  tip  of  the  instrument  entering  the  larynx.  The  bougie  may  be  simply  wet  in 
water,  other  lubricant  being  scarcely  necessary.  The  patient's  mouth  being 
open,  the  surgeon  places  his  left  forefinger  gently  upon  the  dorsum  of  the 
tongue,  depressing  it  and  at  the  same  time  drawing  it  a  little  forward.  The 
bougie  is  held  lightly  in  the  right  hand  and  is  inserted  into  the  mouth  against 
the  posterior  pharyngeal  wall,  and  gently  pushed  onward  and  downward  while 
the  patient  is  directed  to  swallow,  when  the  instrument  usually  glides  readily 
down  the  esophagus  and  into  the  stomach.  If  uncontrollable  retching  occurs,  or 
the  patient  chokes,  he  should  be  directed  to  breathe  slowly  and  deeply ;  or  the 
posterior  wall  and  lower  limit  of  the  pharynx  and  the  base  of  the  tongue  may 
be  painted  with  five-  to  ten-per-cent  cocain  solution.  In  unconscious  patients, 
or  those  with  anesthesia  of  the  larynx,  the  tip  of  the  instrument  must  be  care- 
fully directed  backward  with  the  left  forefinger  as  a  guide,  to  avoid  the  larynx. 
A  tumor  or  retropharyngeal  abscess  or  a  marked  kyphosis  in  the  cervical  region 
may  render  the  introduction  more  or  less  difficult,  as  may,  of  course,  stricture 
of  the  upper  end  of  the  esophagus.  If  the  tube  checks  at  any  point,  a  slight 
withdrawal  and  gentle  advance  will  be  sufficient  to  enable  it  to  pass  except  in 
the  presence  of  a  real  obstruction.  In  delirious  or  insane  patients,  or  in  the 
presence  of  lock-jaw  from  any  cause,  a  slender,  long  tube  may  be  passed  through 
the  nose  into  the  pharynx,  and  so  into  the  gullet.  After  a  solid  instrument 
has  once  entered  the  esophagus  through  the  mouth,  it  is  of  advantage  to  direct 
the  patient  to  incline  his  head  backward  so  that  the  path  of  the  bougie  may 
be  more  straight  and  the  sensation  of  obstruction  may  be  more  readily  com- 
municated to  the  surgeon's  hand.  The  diagnostic  value  of  the  bougie,  etc., 
will  be  considered  under  the  different  pathological  conditions  in  which  they 
are  used. 

II.  Palpation. — Palpation  of  the  esophagus  is  only  possible  in  its  upper 
part.  Through  the  mouth  the  forefinger  may  be  introduced  into  the  beginning 
of  the  gullet,  and  a  foreign  body,  a  stricture,  or  the  presence  of  a  tumor  may 
thus  be  determined.  External  palpation  may  permit  the  detection  of  a  large, 
hard,  foreign  body,  possibly  carcinomatous  infiltration  of  the  surrounding  tis- 


METHODS    OF   EXAMINING   THE   ESOPHAGUS  599 

sues,  or  of  a  large  diverticulum  filled  with  food  or  with  air.     Such  tumor  may 
diminish  in  size  on  manipulation. 

III.  Auscultation. — Certain  sounds  can  be  heard  through  a  stethoscope 
placed  along  the  line  of  the  esophagus  in  the  neck,  or  in  other  situations  to 
he  noted,  during  swallowing.  These  sounds  vary  somewhat  in  normal  and 
pathological  conditions ;  they  are  not  of  great  diagnostic  value.  The  first 
sound  is  supposed  to  be  caused  by  air  compressed  in  the  pharynx  forcing  the 
food  down  the  gullet  during  the  act  of  swallowing ;  the  sound  is  seldom  present, 
and  has  no  pathological  significance.  The  second  sound  is  said  to  be  caused 
by  the  passage  of  air  and  food  through  the  cardiac  orifice  into  the  stomach ;  it 
is  to  be  heard  in  the  back  or  along  the  costal  border  in  front,  to  the  left  of  the 
middle  line,  some  seconds  after  the  food  is  swallowed.  These  two  sounds  are 
said  not  to  be  present  together.  The  second  is  absent  in  cases  of  narrow 
stricture  at  or  above  the  cardia  (v.  Hacker). 

IV.  Percussion. — Percussion  is  rarely  of  value  in  diseases  of  the  esopha- 
gus. A  diverticulum  filled  with  gas  or  food,  if  in  the  upper  part  of  the  gullet, 
will  give  a  tympanitic  or  dull  note  respectively. 

V.  Direct  Inspection,  Esophagoscopy. — v.  Mikulicz  first  used  a  straight  metal 
tube  to  inspect  the  interior  of  the  esophagus.  While  most  of  the  diseases  of  the 
gullet  can  be  diagnosticated  without  this  aid,  the  method  furnishes  accurate 
information,  and  is  not  very  difficult  to  apply.  The  instruments  consist  of 
straight  metal  tubes  from  one  half  to  three  quarters  of  an  inch  in  diameter. 
These  tubes  are  made  in  several  different  lengths,  according  to  the  depth  of 
the  lesion  to  be  examined.  The  lower  end  of  the  tube  is  cut  off  squarely  or 
obliquely.  A  conoidal  hard-rubber  obturator  fills  this  gap  during  the  intro- 
duction of  the  instrument.  The  upper  end  of  the  tube  is  arranged  for  the 
attachment  of  a  suitable  electric  light  and  lens  for  illumination,  or  a  tube  may 
be  used  which  has  a  small,  shaded  electric  light  in  its  interior  near  the  lower 
end.  The  latter  arrangement  is  simple,  and  more  satisfactory  on  account 
of  the  great  length  of  the  tube.  It  is  desirable  that  the  patient's  stomach 
should  be  empty  when  the  tube  is  introduced,  otherwise  regurgitation  of 
food  may  take  place  into  the  tube,  notably  when  it  is  introduced  as  far 
as  the  cardia.  Such  soiling,  when  it  occurs,  must  be  wiped  or  washed 
away,  or,  if  fluid,  may  be  sucked  out  with  a  catheter  and  hand  syringe. 
The  patient  should  be  clad  as  for  a  surgical  operation,  so  that  respiration 
may  be  free.  The  lower  pharynx  is  thoroughly  painted  with  cocain  solu- 
tion (ten  to  twenty  per  cent)  several  minutes  before  the  examination ;  the  tube 
may  be  slightly  lubricated  with  a  soluble  sterile  lubricant ;  Iceland-moss  jelly, 
for  example,  or  glycerin,  although  this  is  not  always  necessary.  The  patient 
then  sits  upright  on  the  table,  the  mouth  is  widely  opened,  the  surgeon  de- 
presses and  draws  forward  the  base  of  the  tongue  with  his  left  forefinger,  and 
introduces  the  tube  with  its  obturator  in  place  to  the  back  of  the  pharynx  and 
downward;  the  patient  then  extends  his  head  so  that  the  mouth  and  gullet 
may  be  as  nearly  as  possible  in  the  same  line ;  the  tube  is  gently  pressed  on- 


600 


THE    ESOPHAGUS 


ward  until  it  engages  in  and  passes  the  narrow  upper  end  of  the  esophagus, 
when  it  usually  moves  on  easily  without  much  resistance  until  it  reaches  the 
sphincter  of  the  cardia. 

The  tube  may  also  be  introduced  and  the  examination  conducted  with  the 
patient  lying  on  his  side,  the  head  being  extended.     When  the  esophagoscope 


Fig.  215. — Esophagoscope  with  Small  Electric  Light  Near  its  Lower  Extremity  for 
Examining  the  Esophagus  by  Direct  Vision. 


or  any  hard  or  partly  flexible  instrument  is  to  be  introduced  under  anesthesia, 
the  patient  is  placed  on  his  back,  with  the  head  hanging  over  the  end  of  the 
table,  properly  supported  and  extended  sufficiently  to  permit  a  straight  instru- 
ment to  pass  through  the  mouth  and  down  the  gullet.  The  surgeon  stands  at 
the  head  of  the  table.  When  searching  for  a  hard,  foreign  body,  the  surgeon 
may  be  deceived  by  the  click  made  when  the  instrument  strikes  the  patient's 
teeth.  In  such  a  case  the  teeth  may  be  covered  by  a  pad  of  gauze,  or  the  like. 
If  the  tube  was  inserted  with  the  patient  sitting  up,  as  soon  as  the  tube  is  intro- 
duced the  patient  is  gently  lowered  to  the  dorsal  position  on  the  table,  with 
his  head  hanging  somewhat  over  the  edge ;  the  obturator  is  then  removed  and 
the  esophagus  inspected  as  the  tube  is  withdrawn.  Should  the  tube  check  at 
any  point  during  its  introduction  the  obturator  is  withdrawn  and  the  seat  of 
the  obstruction  examined  ;  such  may  be  a  foreign  body,  a  stricture  (benign  or 
malignant),  a  diverticulum,  or  the  instrument  may  have  caught  in  a  fold  of 
mucous  membrane  owing  to  an  improper  direction  taken  by  the  advancing 
tube.  Inspection  will  usually  enable  the  surgeon  to  see  how  to  correct  the  direc- 
tion ;  he  moves  the  tube  and  the  patient's  head  a  little  this  way  and  that  until 
the  caliber  of  the  gullet  centers  that  of  the  tube ;  the  obturator  is  reinserted 
and  the  tube  pushed  on.  It  is  to  be  remembered  that  the  esophagus  inclines 
forward  and  to  the  left  after  passing  through  the  diaphragm.  In  the  selection 
of  a  particular  length  of  tube  the  surgeon  will  be  guided  by  the  probable  seat  of 
the  lesion  he  desires  to  examine ;  this  may  be  determined  by  the  previous  intro- 
duction of  a  flexible  bougie  or  bulbous  esophageal  sound. 

While  in  cases  of  impacted  foreign  bodies  the  use  of  the  esophagoscope  is 
always  justifiable,  in  eases  of  acute  inflammation  it  is  not.  If  an  ulcerated 
carcinoma   is  present,  or  in  any  case  where  there  is  reason  to  suspect  that  the 


METHODS    OF   EXAMINING   THE   ESOPHAGUS 


601 


integrity  of  the  wall  of  the  esophagus  is  destroyed  or  weakened — as  in  wounds, 
external  or  internal — the  introduction  should  be  made  with  the  greatest  gen- 
tleness and  care,  and  the  slightest  sign  of  obstruction  should  be  followed  by 
withdrawal  of  the  obturator  and  inspection  of  the  esophagus.  Aneurisms  in  the 
thorax  and  acute  or  chronic  disturbances  of  respiration  of  any  sort  are  contra- 
indications to  this  method  of  examination.  In  cases  of  malignant  disease  a 
small  portion  of  tumor  tissue  may  be  removed  through  the  tube  and  subjected 
to  microscopic  examination;  the  diagnosis  is  thus  rendered  certain.  Impacted 
foreign  bodies  cannot  only  be  seen,  but  the  obstacles  to  their  removal  may  be 
appreciated,  and  often  corrected  and  removed. 

VI.  X-ray  Examination  of  the  Esophagus. — The  X-rays  are  sometimes  use- 
ful for  locating  such  foreign  bodies  as  are  recognizable  by  the  X-rays,  notably 
those  of  metal,  bone,  glass, 
china,  stone,  or  other  more 
or  less  impervious  material 
(see  Fig.  216).  If  the  for- 
eign body  is  large  it  may 
be  located  with  the  fluoro- 
scope  by  viewing  the  neck 
from  various  directions.  If 
it  is  small  it  will  be  neces- 
sary to  make  one  or  more 
radiographs.  These  may 
be  taken  from  side  to  side 
or  antero-posteriorly ;  in 
neither  case  is  it  possible 
to  get  a  very  sharp  picture 
of  the  body  on  account  of 
its  necessary  distance  from 
the  photographic  plate. 
When  the  picture  is  taken 
antero-posteriorly,  the  plate 
should  be  placed  in  front, 
the  X-ray  tube  behind  the  patient.  When  the  foreign  body  lies  in  the 
thoracic  portion  of  the  esophagus  an  effort  should  be  made  to  take  the  pic- 
ture obliquely,  in  order  to  avoid  the  confusion  of  shadows  caused  by  the 
spine  and  the  heart.  Diverticula  and  dilatations  of  esophagus  may  some- 
times be  demonstrated  by  the  X-rays.  The  patient  is  caused  to  swallow  a 
quantity  of  an  emulsion  of  bismuth  subnitrate.  This  material  entering  the 
diverticulum  or  remaining  in  the  dilated  portion  of  the  esophagus,  casts  a 
shadow  on  the  photographic  plate  or  on  the  fluoroscope,  and  the  location  and 
size  of  the  diverticulum  may  thus  be  demonstrated.  A  diverticulum  may  also 
be  demonstrated  by  passing  an  esophageal  bougie  containing  a  lead  core  or 
filled  with  fine  bird  shot:  when  the  bougie  has  entered  the  diverticulum  the 


Fig.  216. — X-ray  Picture  of  the  Thorax  and  Neck  of  a 
Boy  Aged  Ten,  who  swallowed  a  Fifty-Cent  Silver 
Piece.  The  coin  became  impacted  in  the  esophagus,  as 
shown  in  the  illustration.  During  my  efforts  to  remove 
it,  it  passed  on  into  the  stomach.     (Author's  case.) 


602 


THE    ESOPHAGUS 


patient  is  examined  with  the  fluoroscope,  or  a  radiograph  is  taken,   and  the 
abnormal  position  of  the  bougie  may  thus  be  shown. 


CONGENITAL   DEFECTS   OF   THE   ESOPHAGUS 

Imperfect  development  of  the  gullet  may  exist  alone  or  be  associated  with 
other  defects;  in  either  instance  the  children  are  rarely  viable;  the  surgical 
importance  of  these  conditions  is  therefore  small.  The  most  common  deform- 
ity is  that  the  upper  portion  of  the  gullet  ends  below  in  a  blind  sac,  either 


Fig.  217. — Congenital  Atresia  of  the 
Esophagus.  Diagram  to  illustrate  the 
condition  found  in  the  body  of  an  in- 
fant brought  to  the  anatomical  depart- 
ment of  the  Columbia  University  Med- 
ical College.  The  drawings  and  dia- 
gram are  shown  through  the  kindness 
of  Dr.  C.  R.  L.  Putnam.  There  was 
an  atresia  of  the  esophagus  and  an  ab- 
normal communication  between  the 
lower  segment  of  the  esophagus  with 
the  trachea. 

A.  Upper   portion   of   the  esophagus 
ending  below  in  a  blind  sac. 

B.  Lower  portion  of  esophagus  ending 
below  at  C  in  stomach. 

Z>.  Trachea. 

E.  Abnormal  communication  between 
trachea  and  esophagus. 


Fig.  218. — Anterior  Viet 

f  of  Spec 

C". 

Diaphragm. 

c. 

Stomach. 

D. 

Bifurcation  of  bronchi. 

E. 

Abnormal    communication 

between 

gullet. 

if'. 

Heart, 

trachea    and 


INJURIES    OF    THE    ESOPHAGUS 


603 


normal  in  size  or  dilated,  and  usually  intrathoracic.  The  lower  portion  is 
often  short  and  narrow,  and  may  communicate  with  the  trachea  by  a  large  or 
narrow  orifice.  Such  chil- 
dren are  unable  to  swallow; 
attempts  at  nursing  are  fol- 
lowed by  regurgitation  of 
food  through  the  nose.  There 
may  be  a  gurgling  sound  dur- 
ing respiration,  when  mucus 
enters  the  trachea  from  the 
stomach.  Death  occurs  in  less 
than  a  fortnight,  from  inani- 
tion or  pneumonia.  In  some 
cases  the  esophagus  is  of  nor- 
mal size  and  patent,  but  a 
communication  exists  between 
gullet  and  trachea.  If  the 
communication  is  small  or, 
as  sometimes  happens,  does 
not  leak,  no  symptoms  will 
occur.  If  food,  etc.,  passes 
into  the  trachea,  there  will 
be  attacks  of  coughing  and 
choking,  followed  sometimes 
by  septic  pneumonia.  Con- 
genital strictures  of  esopha- 
gus are  very  rare,  a  few  cases 
having  been  observed  at  au- 
topsy; the  individuals  had  a 
history  of  difficulty  in  swal- 


lowing. 


Congenital    dilata- 


tions and  diverticula  of  the 
esophagus  are  rare. '  They 
will  be  considered  under  Dis- 
eases of  the  Esophagus. 


Fig.  219. — Posterior  View  of  Specimen  in  Fig.  218. 
A.    Blind  end  of  upper  portion  of  gullet. 
C".   Diaphragm. 

C.  Stomach. 

D.  Lungs. 

E.  Abnormal  orifice  connecting  trachea  and  gullet. 


INJURIES   OF   THE   ESOPHAGUS 

Wounds  of  the  esophagus  may  be  produced  from  without — incised,  stab, 
and  gunshot  wounds — or  from  within — wounds  caused  by  swallowing  sharp 
or  rough  foreign  bodies,  or  by  the  introduction  of  instruments  into  the  esopha- 
gus for  diagnostic  purposes  or  for  the  extraction  of  foreign  bodies.  Some  of 
the  signs  and  symptoms  of  wounds  and  injuries  of  the  esophagus  have  been 
briefly  referred  to  under  Injuries  of  the  ISTeck  in  General.     Here  they  will  be 


604 


THE   ESOPHAGUS 


considered  somewhat  more  in  detail.  The  incised  wounds  of  the  esophagus 
in  the  neck,  as  already  noted,  are  regularly  associated  with  injuries  of  the 
larynx  and  trachea,  and  frequently  with  injuries  of  important  blood-vessels  and 
nerres.  The  wounds  being  open  to  inspection,  the  diagnosis  presents,  as  a 
rule,  no  difficulties.  In  stab  and  gunshot  wounds,  on  the  other  hand,  the 
depth  and  direction  of  the  wound  canal  can  only  be  inferred,  and  the  presence 
of  a  wound  of  the  esophagus  may  not  be  recognized  in  the  absence  of  the 
escape  of  food,  etc.,  from  the  wound,  pain  on  swallowing,  or  vomiting  of  blood. 
In  these  cases  the  formation  of  an  abscess  or  a  phlegmonous  inflammation  of 
the  neck,  and  the  operative  measures  for  its  relief,  may  first  disclose  the  injury 
to  the  gullet.  Stab  wounds  are  more  often  associated  with  injuries  of  the  large 
vessels  than  are  incised  wounds.  Gunshot  wounds  of  the  esophagus  are  often 
complicated  by  dangerous  bleeding,  and,  in  the  case  of  wounds  made  by  rifle 
bullets,  by  fatal  injury  of  the  vertebra?  and  spinal  cord. 

An  unusual  case  of  gunshot  wound  of  the  neck  which  opened  the  esophagus 
came  under  my  observation.  The  patient  was  a  robust  negro  man,  who  was 
shot  with  a  .32  caliber  pistol.  The  bullet  entered  the  neck  just  at  the  border 
of  the  jaw  and  one  and  one  half  inch  to  the  right  of  the  median  line,  and 
ranged  downward  and  to  the  left.  He  fell  unconscious,  but  soon  recovered  him- 
self and  was  brought  to  the  hospital.     The  bleeding  was  insignificant.     The 

patient  complained  of  pain 
on  swallowing.  By  two  X- 
ray  pictures,  one  of  which 
is  here  reproduced,  the  flat- 
tened bullet  was  located  rest- 
ing upon  the  front  of  the 
transverse  processes  of  the 
fifth  and  sixth  cervical  ver- 
tebra1 on  the  left  side  of  the 
neck.  On  the  third  day  evi- 
dences of  wound  infection 
were  present;  on  the  fourth 
day  tracheotomy  was  done 
for  the  relief  of  threatening 
asphyxia  caused  by  edema 
laryngis ;  the  bullet  was  then 
sought  for  on  the  left  side 
of  the  neck  and  removed. 
During  the  search  it  was 
found  that  the  esophagus 
had  been  opened  by  the  bullet  along  the  left  border,  and  that  the  escape  of  food 
into  the  tissues  had  caused  the  infection.  No  wound  of  the  air  passages  was 
found.  The  esophagus  was  sutured,  and  the  external  wound  was  partly  closed 
and  drained.      No  further  leakage  took  place,  but  the  patient's  recovery  was 


Fig.  220. — X-ray  Picture  of  Bullet  Wound  of  the  Esoph- 
agus Described  in  the  Text,     (Author's  collection.) 


EUPTUEES  AND  PEEFOEATIOXS  OF  THE  ESOPHAGUS    605 

delayed  by  the  suppurative  inilamnuitiuii  beneath  the  deltoid  muscle,  requiring 
incision.     Complete  recovery  followed. 

When  the  wound  involves  both  trachea  and  gullet,  or  larynx  and  gullet,  the 
wounding  of  the  gullet  is  often  indicated  by  the  entrance  of  food  into  the  air 
passages  and  sudden  attacks  of  choking,  coughing,  and  dyspnea.  When  the  esoph- 
agus and  trachea  are  both  completely  divided  by  an  incised  wound,  marked  re- 
traction of  the  divided  ends  takes  place  downward — notably  of  the  esophagus — 
so  that  the  end  of  the  lower  portion  may  be  drawn  below  the  level  of  the  sternum. 
Wounds  of  the  esophagus  and  larynx  or  trachea  may  be  followed  by  a  fistula, 
involving  one  or  both  canals.  The  diagnosis  of  the  fistula?  is  simple:  there  is  an 
escape  of  food  and  mucus  through  the  external  orifice.  If  the  larynx  or  trachea 
are  involved  an  air  fistula  is  present,  and  cicatricial  contraction  may  force  these 
patients  to  wear  a  tracheotomy  tube  permanently.  WTounds  of  the  intrathoracic 
portion  of  the  gullet  are  much  more  apt  to  be  followed  by  mediastinitis,  pleu- 
ritis,  pericarditis,  and  fatal  sepsis  than  those  at  a  higher  level.  These  injuries 
are  usually  associated  with  fatal  lesions  of  the  heart,  lungs,  trachea,  great  ves- 
sels, etc.  The  symptoms  pointing  definitely  to  injury  of  the  esophagus  are  pain 
in  swallowing  and  the  escape  of  food  from  the  wound;  there  is  often  extreme 
thirst ;  there  may  be  hiccough.  Strictures  of  the  esophagus  are  said  not  to 
follow  wounds  of  that  canal.  The  septic  infection  is  accompanied  by  symptoms 
which  vary  somewhat  according  to  whether  the  associated  injuries  involve  the 
lung,  the  pleura,  pericardium,  etc.  Injuries  of  the  air  passages  are  indicated 
by  subcutaneous  emphysema,  cough,  hemoptysis,  escape  of  air  from  the  wound, 
and  dyspnea.  Further  discussion  of  the  topic  will  be  found  under  Injuries  of 
the  Thorax.  The  end  result  of  these  cases  is  usually  death  from  shock,  hemor- 
rhage, or  septic  complications. 

RUPTURES   AND   PERFORATIONS   OF  THE   ESOPHAGUS 

Spontaneous  rupture  of  the  esophagus  is  an  exceedingly  rare  accident ;  the 
few  reported  cases  have  occurred  during  violent  retching  or  vomiting,  or  from 
violent  shocks  to  the  body — jumping  down  from  a  height,  for  example.  It  is 
believed  that  in  nearly  all  cases  the  wall  of  the  canal  has  been  weakened  by 
some  pathological  process.  The  rupture  is  nearly  always  longitudinal,  and 
occurs  just  above  the  diaphragm.  The  pleurae  may  also  be  opened.  The 
symptoms  are  sudden  violent  pain,  referred  to  the  epigastric  region  and  back — 
a  sensation  that  something  has  given  way;  the  patient  usually  passes,  almost 
immediately,  into  collapse.  There  is  the  appearance  of  subcutaneous  emphy- 
sema at  the  root  of  the  neck  from  gas  which  escapes  from  the  stomach  into 
the  mediastinum,  and  finds  its  way  upward.  Severe  pain,,  dyspnea,  a  rapid, 
feeble  pulse,  cyanosis,  suppression  of  urine,  extreme  thirst,  hiccough,  and  death 
in  less  than  forty-eight  hours. 

Perforation  of  the  esophagus  associated  with  disease  of  the  canal  may  occur 
from  without  or  from  within.     The  accident  may  occur  as  a  sudden  rupture  in 


606 


THE   ESOPHAGUS 


cases  of  stricture  during  efforts  to  swallow  food,  or  as  an  ulcerative  process 
in  cases  of  cancer,  tuberculosis,  cauterization  with  alkalies,  carbolic  acid,  etc., 
or  in  other  forms  of  ulceration.  If  the  perforation  takes  place  suddenly  the 
symptoms  are  those  of  rupture.  The  results  are  phlegmonous  mediastinitis, 
empyema,  putrid  bronchitis,  septic  pneumonia,  pericarditis,  gangrene  of  the 
lung,  according  to  the  site  of  the  perforation.  In  most  instances  the  perforation 
takes  place  more  gradually,  and  to  the  original  condition  there  are  added 
sepsis,  and  the  signs  and  symptoms  of  the  lesions  just  named.  Perforations 
from  without  occur  as  the  result  of  malignant  tumors  of  the  neighboring  organs, 
from  acute  or  chronic  suppurative  processes  near  the  esophagus,  from  tuber- 
culous  abscesses   of  the  bodies  of  the  vertebra?,  tuberculous   or   suppurating 

bronchial  glands;  an  aneu- 
rism of  the  aorta  or  other 
large  vessel  may  rupture 
into  the  esophagus,  as  may 
also  an  abscess  of  the  lung 
or  an  empyema.  A  rup- 
ture of  an  aneurism,  of 
course,  results  in  imme- 
diately fatal  hemorrhage. 
Bleeding  from  the  esopha- 
gus cannot  always  be  dif- 
ferentiated from  gastric 
hemorrhage ;  much,  if  not 
all,  of  the  blood  usually 
finds  its  way  into  the  stom- 
ach, and  may  be  subse- 
quently vomited.  The  gen- 
eral symptoms  will  be  those 
of  internal  hemorrhage. 
If  a  stricture  exists  below 
the  seat  of  the  bleeding 
the  blood  will  find  its  way 
into  the  pharynx  and  be 
coughed  up. 

The  slowly  formed  per- 
forations from  other  causes 
are  not  always  immediate- 
ly fatal ;  more  or  less  com- 
pletely walled-off  pus  cav- 
ities may  be  formed  in  the 
mediastinum,  and  slowly 
increase  in  size  and  burrow  in  various  directions,  occasionally  perforating  the 
chest  wall.     The  following  unusual  case  came  under  my  observation.    (See  illus- 


Fig.  221. — Dr.  Dowxes's  Case  of  Esophageal  Fistula.  This 
man  reentered  the  hospital  in  my  service  in  the  autumn  of 
1908,  more  than  three  years  after  the  formation  of  an  arti- 
ficial opening  into  the  stomach.  There  was  very  little  dis- 
charge from  the  esophageal  fistula  and  the  patient  was  able 
to  swallow  food  through  the  normal  channels  quite  well. 
He  had,  however,  failed  greatly  in  health.  The  gastrostomy 
leaked  quite  badly.  The  patient  was  weak  and  emaciated. 
Dr.  Downes  did  an  operation  for  the  closure  of  the  artificial 
opening  into  the  stomach,  but  the  patient  was  so  weak 
that  he  did  not  survive  this  comparatively  slight  operation. 


RUPTURES  AND  PERFORATIONS  OF  THE  ESOPHAGUS 


607 


trnh'on.)  A  n inn  presented  himself  for  treatment  with  a  I  liberculous  ulcer  on  the 
left  border  of  the  sternum,  opposite  the  fourth  costal  cartilage,  which  seemed  to 
communicate  with  the  pos- 
terior surface  of  the  ster- 
num and  discharged  a  good 
deal  of  tuberculous  mate- 
rial. A  scraping  operation 
caused  no  improvement  in 
his  condition,  and  he  passed 
out  of  my  care.  Gradually 
thereafter  he  failed  in  gen- 
eral health  and  became  sep- 
tic. Later  he  came  under 
the  care  of  Dr.  William  A. 
Downes,  who  found  a  large 
tuberculous  cavity  in  the 
mediastinum,  from  which, 
after  a  time,  food  was  dis- 
charged, thus  demonstrating 
an  esophageal  fistula.  A 
gastrostomy  relieved  his 
condition  greatly  so  that 
the  cavity  nearly  or  quite 
healed,  and  the  opening 
in  the  esophagus  closed. 
There  were  never  symp- 
toms of  esophageal  ob- 
struction. 

Another  case  came  under  my  observation  in  1907.  (See  illustration.) 
A  female  child  ten  years  of  age  was  brought  to  the  hospital  much  emaci- 
ated, and  suffering  from  chronic  sepsis;  she  was  said  to  have  been  ill  for 
three  months.  Pneumonia  had  been  the  diagnosis  made ;  upon  examining 
her  it  was  found  that  she  had  the  signs  of  fluid  in  the  upper  part  of  her  right 
chest,  anteriorly.  A  needle  introduced  below  the  clavicle  in  the  second  inter- 
costal space  withdrew  pus.  Resection  of  the  third  rib  opened  a  purulent  col- 
lection in  the  right  pleural  cavity  of  considerable  size.  From  the  opening 
there  escaped  after  the  operation  most  of  the  solid  and  liquid  food  swallowed 
by  the  child.  Efforts  to  pass  instruments  by  the  esophageal  fistula  into  the 
stomach  failed.  The  child  continued  to  fail  slowly.  A  gastrostomy  was  done, 
in  the  hope  that  her  nutrition  might  be  improved;  upon  opening  the  belly, 
extensive  tuberculous  peritonitis  was  discovered ;  abundant  food  was  given 
through  the  gastrostomy  opening,  but  the  patient  gradually  faded  away,  and 
died  some  few  weeks  later. 


Fig.  222. — Author's  Case  of  Esophageal  Fistula.  Eso- 
phageal fistula  in  a  little  girl,  clue  to  tuberculous  ulceration  of 
a  mediastinal  gland  into  the  esophagus,  and  the  formation 
of  a  sacculated  empyema,  which  I  opened  by  removing  a 
portion  of  the  third  rib  in  front.  As  soon  as  the  child  be- 
gan to  swallow  food  a  portion  of  it  escaped  from  the  drain- 
age opening,  thus  establishing  the  diagnosis.  The  child 
subsequently  died  of  a  generalized  tubercular  peritonitis 
and  exhaustion. 


608  THE   ESOPHAGUS 

FOREIGN   BODIES   IN   THE    ESOPHAGUS 

Only  those  foreign  bodies  which  become  impacted  in  the  gullet  are  of  serious 
consequence ;  if  they  reach  the  stomach  they  are  usually,  but  not  always,  passed 
per  rectum  without  difficulty.  The  bodies  usually  gain  an  entrance  through 
the  mouth.  The  commonest  articles  to  become  impacted  are  plates  of  false 
teeth  and  pieces  of  bone.  In  addition  to  these  the  list  is  almost  endless,  and 
includes  articles  hard  and  soft,  smooth  and  rough,  angular  and  sharp,  organic 
and  inorganic,  in  endless  variety,  swallowed  by  accident  or  design.  Children 
and  lunatics  form  a  pretty  large  contingent  of  these  cases,  and  occasionally 
professional  jugglers.  In  cases  of  stricture,  paralysis,  or  dilatation  of  the 
esophagus,  or  when  the  esophagus  is  sharply  bent  or  pressed  upon  by  a  de- 
formity or  the  presence  of  a  tumor  or  aneurism,  bodies  which  ordinarily  would 
find  their  way  easily  into  the  stomach  may  become  lodged. 

There  are  three  situations  corresponding  to  the  physiological  narrow  places 
of  the  gullet  in  which  foreign  bodies  are  apt  to  stop;  they  are:  (1)  The  upper 
end  of  the  gullet,  at  the  level  of  the  cricoid  cartilage;  (2)  at  the  level  of  the 
bifurcation  of  the  trachea,  or  a  little  higher,  opposite  the  level  of  the  bony 
girdle  of  the  superior  orifice  of  the  thorax;  (3)  at  the  level  of  the  dia- 
phragm. 

1.  Large,  soft  masses,  such  as  pieces  of  meat,  potato,  etc.,  are  apt  to  lodge 
in  the  upper  end  of  the  gullet,  as  already  noted  under  Foreign  Bodies  in  the 
Larynx.  Large,  hard,  or  irregular  and  sharp  or  angular  bodies  also  frequently 
lodge  in  this  situation,  and  the  same  is  indeed  true  of  slender,  pointed  bodies — 
needles,  pins,  sharp  bones,  and  sticks  of  wood.  These  latter,  as  they  are  grasped 
by  the  muscles — whether  they  be  included  in  a  bolus  of  food  or  naked — are 
often  pressed  into  the  mucous  membrane  by  the  first  muscular  movement  of 
the  act  of  swallowing.  When  a  large,  hard  body  is  impacted  at  one  of  the 
lower  levels,  it  is  frequently  because  it  has  been  pushed  downward  during  un- 
successful efforts  to  remove  it. 

2.  Such  bodies  as  pass  the  upper  end  of  the  gullet  are  most  apt  to  lodge 
at  the  level  of  the  entrance  to  the  thorax  or  opposite  the  bifurcation  of  the 
trachea. 

3.  The  spontaneous  lodgment  at  the  level  of  the  diaphragm  is  exceptional 
under  normal  conditions  of  the  esophagus. 

The  symptoms  produced  by  the  lodgment  of  foreign  bodies  vary  according 
to  the  size  and  other  physical  characters  of  the  body,  and  according  to  the 
point  of  lodgment.  They  are  partly  obstructive,  partly  due  to  pressure,  and 
partly  to  injury  of  the  wall  of  the  gullet  or  surrounding  structures.  The 
effects,  moreover,  are  immediate  and  remote.  If  the  body  fills  the  upper  end 
of  the  gullet  and  presses  upon  the  larynx,  there  will  be  a  choking  sensation, 
sometimes  severe  dyspnea  and  cyanosis,  involuntary  efforts  to  swallow,  and 
retching.  The  diagnosis  in  such  cases  is  not  difficult ;  a  finger  introduced 
into  the  upper  end  of  the  gullet  through  the  mouth  will  detect  the  body. 


FOREIGN  BODIES  IN  THE  ESOPHAGUS 


609 


The  X-ray  picture  (Fig.  216,  page  001)  shows  a  fifty-cent  silver  piece 
lodged  in  the  esophagus  of  a  boy  aged  ten,  who  swallowed  the  coin  accidentally. 
No  symptoms  were  noted  except  inability  to  swallow  solid  food.  As  shown, 
the  coin  lodged  opposite  the  upper  border  of  the  sternum. 

During  efforts  to  extract  it  the  coin  passed  into  the  stomach  and  remained 
in  the  cardia,  as  shown  by  the  illustration.  After  waiting  ten  days  I  removed 
it  by  gastrotomy.  The  boy  made  an  uneventful  recovery.  If  the  body  is  sharp 
and  not  large  enough  to  oc- 
clude the  gullet,  there  will 
be  pain  in  the  throat,  in- 
creased by  swallowing,  and 
felt  at  a  fixed  point.  If 
the  body  has  passed  below 
the  upper  end  of  the  gul- 
let, the  pain  is  usually  re- 
ferred to  the  sternum,  and 
if  the  body  has  passed  on, 
but  has  wounded  the  gullet 
in  its  passage,  such  pain 
may  be  felt  for  several  days. 
Attempts  to  swallow  fluids 
or  solids  will  be  followed 
by  success  or  by  more  or 
less  complete  regurgitation, 
according  to  the  degree  of 
obstruction.  If  the  gullet 
is  wounded  there  will  be 
more  or  less  bleeding. 
Often  fluids  and  soft  sol- 
ids can  be  swallowed,  while  solid  substances  fail  to  pass  (see  Figs.  216  and 
223). 

The  ultimate  results  of  the  impaction  of  hard  substances  in  the  gullet  are 
very  varied.  They  may  remain  quiescent  for  an  indefinite  time,  and  even 
be  forgotten.  Slender,  sharp  bodies  (needles)  may  perforate  the  wall  of  the 
gullet  and  travel  to  distant  parts  of  the  body,  finally  appearing  under  the  in- 
tegument. In  the  ISTew  York  State  Hospital  for  the  Insane,  at  Utica,  a  woman 
was  admitted  who  had  been  a  seamstress ;  during  her  stay  in  the  hospital  there 
appeared  under  the  skin  of  her  trunk  and  limbs  sewing  needles  of  various  sizes ; 
these  needles  to  the  number  of  several  hundred  were  extracted  from  time  to 
time.  It  was  believed  that  the  needles  had  been  swallowed  before  her  entrance 
to  the  hospital.  Rough,  angular,  and  sharp  bodies  ordinarily  cause  pressure 
necrosis  of  the  w7all  of  the  gullet;  such  ulceration  may  be  long  delayed.  The 
results  are  various.  The  body  may  finally  perforate  the  wall  of  any  of  the 
large  vessels  and  cause  fatal  bleeding ;  such  bleeding  is  often  preceded  by  slight 
40 


Fig.  223. — X-ray  Picture  of  a  Tin  Whistle  Impacted  in 
the  Esophagus  of  a  Boy  Aged  Six.  Under  a  general 
anesthetic  I  was  able  to  extract  the  whistle  with  a  coin- 
catcher  without  much  difficulty. 


610  THE   ESOPHAGUS 

hemorrhages.  The  presence  of  ulceration  may  be  inferred  from  pain  and  a 
bloody,  purulent  discharge,  coughed  or  vomited  up  from  time  to  time.  Per- 
foration into  the  trachea  or  a  bronchus  is  followed  by  putrid  bronchitis  or 
septic  pneumonia.  Perforation  into  the  mediastinum  by  phlegmonous  inflam- 
mation. There  may  also  occur  phlegmonous  inflammation  of  the  esophagus 
itself,  pericarditis,  emphysema,  pyopneumothorax,  perichondritis  of  the  lar- 
ynx, etc. 

The  diagnosis  of  the  presence  of  a  foreign  body  can  often  be  made  readily 
from  the  history  and  the  symptoms,  as  already  described.  It  is,  however,  most 
desirable  that  the  presence  and  situation  of  the  body  should  be  demonstrated. 
There  is  sometimes  a  doubt  in  the  mind  of  both  surgeon  and  patient  unless  the 
body  is  passed  per  rectum,  because  a  body  which  wounds  the  mucous  membrane 
may  leave  behind  pain  and  soreness  for  some  days.  If  the  body  is  in  the 
pharynx  or  upper  end  of  the  gullet,  it  can  usually  be  felt  with  the  forefinger 
or  seen  in  the  laryngoscopic  mirror.  If  it  is  large  and  hard  and  in  the  cervical 
portion  of  the  gullet,  it  can  often  be  felt  by  external  palpation  of  the  neck, 
usually  upon  the  left  side.  The  sensation  given  to  the  surgeon's  fingers  may 
be  slight  or  doubtful,  but  the  patient  will  complain  of  distinct  tenderness  over 
a  fixed  point.  If  the  body  has  already  caused  ulceration  and  inflammatory 
infiltration  of  the  surrounding  tissues,  these  lesions  will  give  their  own  easily 
recognizable  signs  and  symptoms — pain,  tenderness,  swelling,  induration,  some- 
times emphysema,  and  the  general  symptoms  of  sepsis.  If  it  is  metallic,  it  can 
be  located  by  the  X-rays.  Examination  with  a  full-sized  graduated  bougie  or 
bulbous  bougie,  with  an  olive-shaped  tip,  will  usually  detect  an  obstruction  if 
the  body  is  low  down.  If,  however,  such  a  body  is  not  so  situated  as  to  mate- 
rially narrow  the  canal,  and  is  coated  with  mucus,  the  bougie  may  pass  it  and 
the  surgeon  may  believe  the  body  has  gone  into  the  stomach.  The  greatest 
care  and  gentleness  should  be  used  in  the  examination  of  these  cases,  lest 
damage  be  done  to  the  gullet. 

In  examining  with  a  graduated  bulbous  bougie,  the  bulb  of  metal  or  ivory 
will  give  to  the  surgeon's  hand  a  grating  sensation,  or  the  like,  when  a  hard 
foreign  body  is  touched ;  a  sound,  even,  may  be  audible.  The  surgeon  should 
be  careful  that  he  does  not  mistake  the  sound  or  sensation  caused  by  the  shaft 
of  the  instrument  striking  the  teeth  for  that  produced  by  a  body  in  the  gullet. 
The  teeth  may  be  covered  by  a  pad  of  gauze.  When  the  body  is  thus  located 
its  distance  from  the  teeth  should  be  noted  on  the  shaft  of  the  instrument.  A 
very  certain  method  of  examination  is  by  the  use  of  the  esophagoscope.  The 
body  may  thus  be  seen  and  obstacles  to  its  removal  appreciated  and  sometimes 
overcome.  If  the  body  is  small  the  tube  should  be  withdrawn  very  slowly,  lest 
the  body  escape  observation  by  the  intervention  of  a  fold  of  mucous  membrane. 
Hyperemia,  wounds,  abrasions,  ulcerations  caused  by  the  foreign  body,  may 
also  be  detected. 


DISEASES    OF    THE    ESOPHAGUS  611 

DISEASES   OF   THE   ESOPHAGUS 

Acute  and  Chronic  Catarrhal  Inflammations  of  the  Esophagus. — Acute  and 
chronic  catarrhal  inflammations  of  the  esophagus  are  neither  of  them  of  much 
surgical  interest.  Acute  catarrh  results  from  mechanical,  thermal,  chemical 
irritation  of  the  mucous  membrane ;  is  characterized  by  hyperemia  and  an  in- 
creased discharge  of  mucus.  The  patient  suffers  some  pain  on  swallowing  food. 
The  lesions  can  be  recognized  through  the  esophagoscope.  Chronic  catarrh  is 
common  among  drunkards,  and  may  accompany  benign  or  malignant  stricture 
of  the  gullet  as  well  as  dilatation  and  diverticula.  It  may  accompany  diseases 
of  the  heart  and  cirrhosis  of  the  liver.  The  mucous  membrane  is  thickened ; 
there  is  an  increased  secretion  of  mucus.  Necrotic  and  diphtheritic  inflam- 
mations of  the  gullet  occur  as  the  result  of  trauma,  as  complications  of  acute 
infectious  diseases,  and  from  an  extension  of  a  diphtheritic  inflammation  of 
the  pharynx.  .  They  are  interesting  because  they  may  give  rise  to  stricture. 

Phlegmonous  Inflammation  of  the  Gullet. —  Phlegmonous  inflammation  of  the 
gullet  begins  in  the  submucous  tissue.  It  may  be  localized  or  diffuse.  The 
condition  is  a  rare  one.  It  may  follow  internal  trauma  from  a  foreign  body 
or  occur  as  an  extension  from  a  similar  process  in  the  stomach  or  the  perfora- 
tion of  the  esophagus  from  without  by  purulent  foci  in  the  vicinity.  If  such 
a  focus  breaks  at  the  same  time  into  the  trachea,  a  fistulous  communication 
between  trachea  and  gullet  may  be  formed.  There  appears  to  be  but  little 
tendency  for  purulent  inflammation  originating  in  the  submucous  tissue  of  the 
gullet  to  perforate  into  the  mediastinum,  pleura,  etc.  Usually  pus  forms  be- 
tween the  mucous  and  the  muscular  coat  and,  perforating  the  mucous  mem- 
brane, empties  into  the  esophagus  itself. 

Symptoms. — The  condition,  uncomplicated  by  the  presence  of  a  foreign 
body,  is  not  itself  very  easy  to  recognize.  The  patients  suffer  from  d}^sphagia, 
pain  referred  to  the  sternum  and  back,  constitutional  depression  and  fever, 
sometimes  nausea  and  vomiting.  If  the  abscess  breaks  into  the  gullet,  there 
may  be  cough  and  expectoration  or  vomiting  of  pus.  If  the  process  could  be 
diagnosticated  it  might  be  possible  to  incise  a  localized  abscess  through  the 
esophagoscope.  In  the  case  of  an  impacted  foreign  body  this  has  been  done 
by  v.  Hacker,  with  a  favorable  result. 

Cauterizations  of  the  Esophagus  by  Corrosive  Liquids. — When  swallowed  by 
accident  or  design,  the  caustic  alkalies  and  acids  cause  a  violent  inflammation 
of  the  esophagus.  The  associated  injuries  of  the  mouth,  larynx,  and  stomach 
are  often  so  severe  as  to  produce  death  from  shock,  from  the  specific  action 
of  the  poison,  from  perforation  of  the  stomach  or  esophagus  with  resulting 
peritonitis  or  mediastinitis,  etc.  The  history,  the  characteristic  burns  of  the 
mucous  membrane  of  the  mouth  and  pharynx,  the  appearance  of  the  eschars, 
the  odor  (carbolic  acid),  the  intense  pain,  vomiting,  and  constitutional  symp- 
toms, render  the  diagnosis  easy.  The  condition  is  interesting  from  a  surgical 
point  of  view  in  those  milder  cases  where  the  patient  survives,  the  sloughs 


612  THE   ESOPHAGUS 

separate,  and  cicatricial  contraction  follows  with  the  production  of  a  stricture 
of  the  gullet.      (See  Stricture  of  the  Esophagus.) 

Syphilitic  "Ulceration  of  the  Esophagus. — Syphilitic  ulceration  of  the  esopha- 
gus is  rare.  Most  cases  occur  as  a  gummatous  infiltration  and  ulceration  of 
the  lower  part  of  the  pharynx  and  upper  part  of  the  gullet,  giving  rise  to 
characteristic  symptoms  and  signs  which  are  recognizable  on  inspection.  Upon 
healing  they  may  cause  stricture.  In  the  absence  of  confirmatory  signs  else- 
where  it  would  be  difficult  to  discriminate  between  syphilitic  and  other  forms 
of  ulceration  of  the  esophagus  at  its  deeper  portions  except  through  the  admin- 
istration of  iodid  of  potash  and  the  use  of  the  esophagoscope. 

Tubercular  Ulceration  of  the  Esophagus. — Tubercular  ulceration  of  the 
esophagus  is  a  rare  condition.  The  cases  mentioned  under  Perforations  of  the 
Gullet  might  properly  be  classed  as  a  tuberculous  invasion  of  the  esophagus 
from  without,  arising  probably  from  a  tuberculous  bronchial  gland.  Super- 
ficial and  deep  tubercular  ulcerations  of  the  gullet  have  been  described  asso- 
ciated with  other  tubercular  lesions  and  tubercular  ulcerations  of  the  upper 
end  of  the  gullet  associated  with  tuberculous  ulceration  of  the  pharynx.  The 
symptoms  may  be  marked  dysphagia  and  pain,  or  in  some  cases  symptoms 
have  been  wanting. 

Peptic  Ulcer  of  the  Esophagus. — Round  or  peptic  ulcer  occurs  only  at  the 
lower  end  of  the  gullet,  near  the  cardia.  It  is  a  rare  condition,  supposed  to 
be  due  to  causes  similar  to  those  producing  ulcer  of  the  stomach.  The  symp- 
toms also  are  similar — pain  and  vomiting  of  blood.  If-  the  ulcer  perforates, 
mediastinitis,  empyema,  gangrene  of  the  lung,  pyopneumothorax,  etc.,  may 
follow;  if  it  heals,  stricture  or  pocketing  of  the  esophagus.  The  diagnosis 
with  the  esophagoscope  would  be  possible. 

Stricture  of  the  Esophagus. — Obstruction  of  the  esophagus  may  be  produced 
by  lesions  of  the  wall  of  the  gullet  itself,  internal  causes,  or  by  pressure  from 
without,  external  causes.  The  strictures  produced  by  internal  causes  may  be 
divided  into  inflammatory  and  cicatricial  strictures,  such  as  follow  the  inges- 
tion of  caustic  alkalies  and  acids,  or  ulcerations  due  to  syphilis,  peptic 
ulcer,  or  ulceration  from  the  pressure  of  a  foreign  body,  or  phlegmonous 
esophagitis;  strictures  due  to  malignant  growths  (carcinoma),  spasmodic  stric- 
ture, and  congenital  stricture. 

Obstruction  of  the  gullet  may  also  be  produced  by  the  presence  of  a 
foreign  body  in  the  esophageal  canal,  by  diverticula,  and  by  polypoid  or  other 
benign  tumors  which  obstruct  its  lumen  without  producing  a  true  narrowing 
of  its  caliber.  Of  the  true  strictures,  by  far  the  most  frequent  causes  are  cica- 
tricial contraction  following  the  ingestion  of  caustic  alkalies  and  acids,  and 
carcinoma  of  the  gullet,  the  latter  being  more  frequent.  Those  produced  by 
syphilis,  ulceration  from  pressure  of  a  foreign  body,  are  rare.  Stricture  from 
peptic  ulcer  is  exceedingly  rare.  The  cicatricial  strictures  following  cauter- 
izations occur  most  commonly  at  the  three  physiological  narrow  places  already 
mentioned.     The  same  is  true  of  malignant  strictures. 


DISEASES    OF   THE   ESOPHAGUS  613 

Cicatricial  strictures  may  be  valvelike  or  membranous,  annular  or  tubular, 
according  to  the  depth  and  superficial  extent  of  the  destructive  process  preceding 
their  formation.  The  esophagus  above  the  level  of  the  stricture  is  often  dilated. 
According  to  V.  v.  Hacker,  the  narrowest  cicatricial  strictures  occur  at  the  lower 
portion  of  the  gullet.  When  the  destructive  process  has  involved  the  entire 
thickness  of  the  gullet  and  periesophageal  adhesions  have  formed,  there  may 
occur  angular  deviations  in  the  direction  of  the  tube.  In  these  cases  a  false 
passage  is  easily  made  by  the  incautious  introduction  of  a  bougie.  In  some 
cases  the  gullet  at  the  entrance  to  the  stricture  or  in  the  course  of  a  tubular 
stricture  may  be  softened  or  ulcerated,  and  in  these  situations  also  false  pas- 
sages are  easily  produced. 

Spasmodic  strictures,  with  the  exception  noted  under  Cardiospasm,  occur 
in  neurotic,  usually  hysterical,  individuals.  Congenital  strictures  are  rare. 
They  have  been  occasionally  observed  at  autopsy  as  valvelike,  membranous  pro- 
jections of  the  mucous  membrane  of  the  gullet  in  individuals  who  have  given 
a  history  of  difficulty  in  swallowing.  The  external  causes  of  obstruction  of  the 
gullet  are  acute  inflammatory  infiltration  or  abscess  in  the  surrounding  parts, 
masses  of  lymph  nodes,  often  tubercular  or  due  to  Hodgkin's  disease;  new 
growths,  of  the  thyroid  or  other  structures  in  the  neck,  especially  those  which 
are  malignant,  mediastinal  growths,  aneurisms,  especially  of  the  arch  of  the 
aorta,  and  deformities  of  the  spine. 

Symptoms. — The  most  prominent  symptom  of  all  strictures  is  difficulty 
in  swallowing  food.  If  the  obstruction  occurs  suddenly,  there  may  be  total 
inability  to  swallow.  If  the  obstruction  is  high  up,  the  effort  to  swallow  is 
followed  by  immediate  regurgitation  through  the  nose  and  mouth.  If  lower 
down,  an  interval  may  elapse  before  regurgitation  occurs.  If  the  obstruction 
is  slowly  formed  the  symptoms  gradually  increase  in  severity.  Cases  of  cica- 
tricial stricture  following  the  ingestion  of  caustics  are  at  first  of  an  acute 
inflammatory  character.  The  obstruction  may  be  more  or  less  marked ;  efforts 
to  swallow  are  attended  by  severe  pain.  As  the  acute  inflammation  subsides 
the  symptoms  of  obstruction  may  entirely  pass  away,  to  be  followed  by  gradually 
increasing  difficulty  in  swallowing  which  may  not  appear  for  many  months, 
and  is  not  attended  by  pain.  Fluids  and  soft  solids  are  usually  most  easily 
swallowed,  and  these  patients  learn  to  chew  their  food  very  thoroughly,  to  eat 
very  slowly,  and  to  swallow  small  quantities  at  a  time.  Dilatation  above  the 
stricture  often  occurs,  and  food  accumulates  in  the  dilated  part;  a  catarrhal 
condition  is  then  established,  with  frequent  regurgitation  of  foamy  fluid  mixed 
with  food  and  of  thick,  stringy  mucus,  causing  much  annoyance.  The  material 
regurgitated  contains  no  free  hydrochloric  acid.  The  position  of  the  stricture 
may  be  accurately  located  by  the  patient  or  not.  For  example,  he  may  locate  it 
at  the  root  of  the  neck  when  in  reality  it  is  much  lower  down.  As  the  ob- 
struction increases  the  nutrition  begins  to  suffer,  and  a  severe  grade  of  emacia- 
tion and  anemia  is  finally  reached,  ending  in  death  from  starvation  unless 
relief  is  afforded. 


614  THE   ESOPHAGUS 

Spasmodic  Strictures  of  Nervous  Origin. — Spasmodic  strictures  of  nervous 
origin  are  characterized  in  most  instances  by  variability  in  the  degree  of 
obstruction  which  is  at  times  absolute  and  at  times  slight  or  absent.  There 
are  usually  present  marked  symptoms  of  a  neurotic  or  hysterical  habitus.  The 
spasm  has  usually  appeared  suddenly.  Profound  disturbances  of  nutrition  are 
rare,  but  have  been  reported  in  a  few  cases.  I  have  recently  seen  a  case  in  a 
highly  neurotic  young  man,  who  informs  me  that  he  has  eaten  no  solid  food 
for  three  years.  He  is  fairly  nourished,  and  a  full-sized  bougie  passes  readily 
enough  into  the  stomach  after  the  spasm  at  the  upper  end  of  the  gullet  has  been 
overcome  by  gentle  pressure.  A  special  form  of  spasmodic  stricture  was  de- 
scribed by  v.  Mikulicz  under  the  name  of  Cardiospasm.  The  condition  is 
attended  by  a  spasmodic  closure  of  the  cardiac  end  of  the  esophagus,  such 
that  food  does  not  properly  pass  into  the  stomach.  Eccentric  hypertrophy  and 
dilation  of  the  lower  portion  of  the  esophagus  follows,  with  retention  and 
decomposition  of  food,  and  chronic  inflammation  of  the  gullet.  The  quantity 
of  food  retained  in  the  gullet  may  amount  to  as  much  as  half  a  liter.  The 
disease  occurs  during  middle  and  advanced  life,  and  ends,  if  unrelieved,  in 
death  from  inanition.  In  some  instances  carcinoma  of  the  gullet  has  devel- 
oped and  ended  life.  The  differential  diagnosis  from  carcinoma  can  only  be 
made,  according  to  v.  Mikulicz,  by  the  esophagoscope.  It  could  readily  be 
made  through  a  e;astrotomv  wound. 

Diagnosis. — The  most  important  aid  in  the  diagnosis  of  the  presence,  seat, 
and  caliber  of  a  stricture  is  examination  with  esophageal  bougies.  One  selects 
a  cylindrical  bougie  of  full  size,  or  even  a  soft-rubber  stomach-tube,  or  a  good- 
sized  olivary  bougie,  such  as  would  pass  in  a  normal  gullet ;  by  this  means  the 
depth  of  the  stricture  is  determined,  and  certain  possible  errors  are  avoided. 
A  slender  instrument  might  be  caught  in  a  fold  of  mucous  membrane  or  in  a 
valvelike  stricture,  or  a  pocket,  while  a  larger  one  might  pass.  After  the 
depth  of  the  stricture  has  been  determined,  instruments  of  smaller  caliber  are 
introduced  until  one  is  found  which  enters  or  passes  the  stricture.  Usually 
when  the  instrument  has  entered  the  stricture  it  will  be  firmly  grasped  by  the 
cicatricial  tissue,  and  although  its  further  progress  is  possible,  it  will  be  with 
a  distinct  sense  of  resistance  that  the  bougie  is  moved  either  onward  or  with- 
drawn. When  the  obstruction  of  the  esophagus  is  due  to  the  pressure  of  en- 
larged glands,  a  mediastinal  tumor,  or  other  external  cause,  the  instrument 
may  enter  the  narrowed  portion  with  difficulty,  but  once  it  has  passed  the 
obstruction,  its  further  progress  or  withdrawal  is  not  opposed.  According  to 
v.  Hacker,  in  such  cases  a  soft-rubber  stomach-tube  may  pass  more  easily  than 
a  firm  instrument.  In  passing  an  instrument  through  a  narrow,  tortuous, 
or  eccentrically  placed  stricture,  notably  when  the  gullet  is  dilated  above,  a 
good  deal  of  patience  may  be  necessary  to  engage  the  point  of  the  instrument 
in  the  orifice.  Tn  such  cases  the  bougie  is  withdrawn  a  little,  then  advanced, 
rotated  gently,  inclined  to  one  wall  of  the  gullet  or  the  other,  etc.  The  sur- 
geon thus  learns  the  peculiarities  of  that  particular  case. 


DISEASES    OF    THE    ESOPHAGUS 


615 


diagnosis    between    cicatricial    and 


If  an  olivary  instrument  is  used  the  length  of  the  strictured  portion  may 
sometimes  be  determined.  The  olive  once  it  has  passed  the  stricture  moves  easily 
back  and  forth.  Upon  withdrawal,  the  stricture  will  grasp  the  shoulder  of  the 
olive  and  offer  a  resistance  throughout  a  greater  or  less  distance.  If  there  be 
several  strictures,  it  will  be  impossible  to  determine  the  caliber  of  the  lower 
ones,  unless  they  be  narrower  than  those  above  or  until  the  upper  ones  have  been 
dilated.  If  a  solid  bougie  can  be  moved  more  or  less  freely  from  side  to  side 
above  the  stricture,  a  dilatation  of  the  gullet  is  probably  present. 

Differential  Diagnosis  Between  Cicatricial  and  Malignant  Stric- 
ture of  the  Esophagus. — Differential 
malignant  stricture  may  be  arrived  at 
from  a  variety  of  data.  We  may  prop- 
erly consider  here  the  clinical  history  of 
carcinoma  of  the  esophagus.  The  dis- 
ease occurs  in  advanced  life,  is  rare  be- 
fore the  fortieth  year;  more  than  half 
the  cases  occur  after  fifty  years  of  life; 
men  are  more  often  affected  than  women 
in  the  proportion  of  three  or  four  to 
one.  The  flat  epithelial-celled  cancer  is 
the  common  type;  cylinder-celled  and 
other  forms  are  rare.  The  physiolog- 
ical narrowings  are  favorite  sites.  In 
most  cases  the  tumor  originates  in  the 
gullet,  occasionally  as  an  extension  from 
cancer  of  surrounding  structures.  The 
relative  frequency  of  the  disease  in  dif- 
ferent portions  of  the  gullet  is  as  fol- 
lows: Opposite  the  bifurcation  of  the 
trachea,  at  the  level  of  the  diaphragm 
at  the  cardia,  in  the  neck,  in  the  or- 
der given.  The  tumor  may  be  small  or 
massive,  a  portion  of  the  caliber  only 
may  be  the  seat  of  the  disease  in  its 
early  stages,  usually  the  entire  circumference  of  the  tube  is  cancerous.  Sec- 
ondary tumors  often  form  in  the  lymph  nodes  at  the  root  of  the  neck  and 
in  the  mediastinum.  True  metastases  may  occur  in  the  liver.  The  duration 
of  life  may  be  less  than  a  year  from  the  first  symptoms  or  may  be  as  long 
as  two  years.  The  symptoms  are  gradually  increasing  difficulty  in  swallow- 
ing ;  pain,  a  common  but  not  invariable  symptom ;  emaciation,  which  is  pro- 
gressive, ending  in  cachexia  and  death  from  inanition,  or  from  other  causes; 
among  them  perforation  into  the  pleura,  followed  by  septic  or  putrid  pleuritis ; 
into  the  trachea,  with  septic  pneumonia,  putrid  bronchitis,  or  gangrene  of  the 
lung ;  into  the  aorta,  or  other  great  vessel,  with  death  from  hemorrhage ;  septic 


Fig.  224.  —  Cancer  of  the  Esophagus, 
Showing  Dilatation  of  the  Gullet 
above  the  Stricture.  Perforation  of 
the  gullet  which  caused  a  putrid  medi- 
astinitis  from  which  the  patient  died. 
The  point  of  stricture  is  at  A.  (New 
York  Hospital,  Pathological  Department.) 


616  THE   ESOPHAGUS 

thrombosis  of  a  vein  and  pyemia.  The  dysphagia  is  progressive.  Solid  food, 
soft  solids,  and  finally  fluids,  are  swallowed  with  difficulty,  and  are  regurgi- 
tated at  once,  if  the  stricture  is  high  up;  after  an  interval,  if  lower  down. 
With  the  food  thick  mucus  is  regurgitated  in  quantity,  sooner  or  later  streaked 
with  blood,  indicating  ulceration.  The  regurgitation  may  occur  quietly  and 
without  effort,  or  be  accompanied  by  retching.  When  ulceration  occurs,  par- 
ticles of  tumor  tissue  may  be  brought  up;  such  ulceration  may  be  acompanied 
by  sloughing  of  tumor  tissue,  and  a  temporary  increase  in  the  caliber  of  the 
gullet  with  improvement  in  the  dysphagia  and  in  the  general  condition.  Com- 
monly the  ulceration  is  accompanied  by  putrefactive  changes  and  a  fetid  breath. 

Pain. — In  some  cases  pain  or  discomfort  may  be  felt  before  obstructive 
symptoms  are  manifest.  The  pain  may  be  of  a  dull  or  of  a  sharp,  tearing  char- 
acter. It  is  increased  by  swallowing,  during  which  severe  spasmodic  pain 
may  occur.  The  pain  may  be  referred  to  the  back,  or  to  the  root  of  the  neck,  or 
may  be  felt  in  the  back  of  the  neck  and  radiate  into  the  shoulders.  It  is  some- 
times felt  at  night.  .  In  some  cases  pain  is  absent,  and  in  no  case  is  it  a  symp- 
tom of  great  diagnostic  value. 

Emaciation  and  Weakness. — Emaciation  occurs  early  in  the  disease  as 
well  as  loss  of  strength,  and  is  usually  more  rapid  than  is  the  case  with  cica- 
tricial strictures.  When  the  tumor  ulcerates  there  is  added  chronic  sepsis 
with  an  evening  rise  of  temperature.  When  the  tumor  has  infiltrated  the  sur- 
rounding tissues  there  may  be  symptoms  of  pressure  on  the  cervical  sympa- 
thetic, usually  on  the  left  side,  drooping  of  the  eyelid,  smallness  of  the  pupil, 
which  reacts  but  slowly  to  light,  and  retraction  of  the  globe.  Pressure  on  or 
involvement  of  the  recurrent  nerves  may  cause  more  or  less  severe  dyspnea, 
as  may  also  involvement  of  or  pressure  upon  the  lower  end  of  the  trachea  or 
the  left  bronchus.  In  making  a  diagnosis,  the  age  of  the  patient,  if  over 
forty ;  absence  of  a  history  of  chemical  or  mechanical  trauma ;  absence  of  the 
signs  of  aortic  aneurism;  the  frequency  of  the  disease  in  males;  the  history 
of  progressive  dysphagia ;  emaciation  and  loss  of  strength — strongly  favor  a 
malignant  growth.  Syphilitic  strictures  are  rare.  They  are  usually  situated 
in  the  upper  part  of  the  gullet.  A  history  of  infection  may  be  obtained.  Their 
progress  is  slower;  ulceration,  if  present,  usually  heals  under  large  doses  of 
iodid,  the  subsequent  history  being  that  of  cicatricial  stricture.  Enlargement 
of  lymph  nodes  at  the  root  of  the  neck  is  absent. 

Physical  Examination. — A  tumor  or  thickening  of  the  gullet  can  only  be 
felt  if  the  cancer  is  above  the  sternum.  Enlarged  hard  glands  at  the  root  of 
the  neck  in  conjunction  with  symptoms  of  progressive  obstruction  favors  a 
malignant  growth.  Examination  with  bougies:  Usually  a  bougie  of  suitable 
size  will  detect  an  obstruction  more  or  less  marked.  Exceptions  are  cases  in 
which  the  tumor  does  not  surround  the  gullet ;  cases  in  which  sloughing  of  the 
tumor  has  occurred.  Some  bleeding  often  follows  even  the  most  gentle  intro- 
duction of  the  bougie,  and  if  a  hollow  bougie  with  a  lateral  eye  is  used,  frag- 
ments of  tumor  tissue  may  be  brought  away.     Under  the  microscope  these  may 


DISEASES    OF   THE    ESOPHAGUS  617 

confirm  the  diagnosis.  By  means  of  direct  examination  through  the  esophago- 
scope,  the  differential  diagnosis  between  cicatricial  and  malignant  stricture 
is  possible.  The  white  areas  and  bands  of  scar  tissue  are  very  different  in 
appearance  from  the  infiltrated,  ulcerated  surfaces  of  cancer.  The  raw  surface 
is  covered  by  vascular  granulations,  which  bleed  freely  and  readily,  or  with 
foul  necrotic  tissue.  In  cases  of  cancer  it  is  usually  possible  to  nip  off  a  bit 
of  tissue  by  means  of  a  suitable  forceps  for  microscopic  examination,  thus 
establishing  a  positive  diagnosis  at  once. 

Spasmodic  stricture  in  the  upper  portion  of  the  gullet  can  usually  be 
overcome  by  gentle,  patient  effort  with  a  full-sized  bougie.  If  necessary,  the 
patient  may  be  anesthetized.  Cardiospasm  can  best  be  recognized,  according 
to  v.  Mikulicz,  through  the  esophagoscope.  Pressure  upon  and  even  true  stric- 
ture of  the  gullet  may  be  caused  by  tuberculous  glands  situated  near  the 
bifurcation  of  the  trachea,  forming  adhesions  to  or  rupturing  into  the  gullet. 
The  condition  might  be  recognized  by  other  evidences  of  tuberculosis  and  the 
esophagoscope.  Xew  growths  of  the  thyroid  as  a  cause  of  obstruction  are 
easily  recognized  if  malignant.  Mediastinal  tumors  and  aneurism  as  a  cause 
of  obstruction  must  be  recognized  by  their  physical  signs  or  by  the  X-rays. 
It  is  to  be  remembered  that  tumors  do  not  cause  obstruction  unless  they  sur- 
round or  infiltrate  the  gullet.  In  old  people,  thickening  and  hardening  of  the 
posterior  portion  of  the  cricoid  cartilage  may  give  rise  to  difficulty  in  swal- 
lowing. It  is  to  be  recognized  by  digital  examination  of  the  pharynx,  by  lar- 
yngoscopy examination,  and  by  the  passage  of  bougies. 

Dilatations  of  the  Esophagus. — Dilatations  of  the  esophagus  occur  above 
strictures,  whether  cicatricial  or  malignant,  as  well  as  in  cases  of  cardiospasm. 
They  are  to  be  recognized  by  the  symptoms  mentioned  under  cardiospasm — 
namely,  regurgitation  of  undigested  food  and  catarrh  of  the  gullet.  Further, 
by  the  extraordinary  mobility  of  instruments  in  the  dilated  portion  and  the 
difficulty  of  reaching  the  stomach.  A  positive  diagnosis  of  the  exact  condition 
can  be  arrived  at  only  through  the  esophagoscope.  As  already  suggested  in 
regard  to  diverticula,  an  X-ray  picture  taken  after  the  patient  has  swallowed 
a  quantity  of  bismuth  emulsion  would  be  a  useful  aid  in  the  diagnosis.  The 
following  procedure  was  proposed  by  Rumpel  as  a  means  of  differentiation 
between  diffuse  dilatation  of  the  esophagus  and  diverticulum :  A  tube  is  intro- 
duced into  the  stomach.  This  tube  is  perforated  laterally  here  and  there,  a 
second  tube  is  introduced  into  the  dilated  portion  of  the  gullet,  colored  fluid 
is  then  injected  into  this  second  tube.  If  the  fluid  returns  by  the  tube  in  the 
stomach,  a  dilatation  is  present;  if  only  by  the  second  tube,  a  diverticulum. 

Diverticula  of  the  Esophagus. — A  localized  distention  of  the  gullet  with 
the  gradual  formation  of  a  sac  of  greater  or  less  extent,  lined  by  mucous  mem- 
brane and  blind  at  its  distal  end,  is  known  as  a  diverticulum.  Zenker  divided 
these  pouches  into  two  groups,  according  to  their  causation :  Diverticula  aris- 
ing by  pressure  from  within,  "  pulsion  diverticula  " ;  diverticula  arising  from 
traction  upon  the  gullet  from  without,    "  traction   diverticula."      They   may 


618  THE   ESOPHAGUS 

further  be  divided  for  purposes  of  description  into  those  occurring  in  the 
upper  and  lower  parts  of  the  esophagus  respectively.  Diverticula  are  rare 
conditions. 

Pulsion  Diverticula  of  the  Upper  Portion  of  the  Esophagus. — 
These  occur  more  often  in  men  than  in  women.  They  rarely  cause  symptoms 
until  middle  life  or  later.  The  bulging  of  the  wall  of  the  gullet  usually 
begins  on  the  posterior  wall  and  a  little  to  the  left  of  the  middle  line,  and 
in  this  type  is  always  opposite  the  level  of  the  cricoid  cartilage.  It  has  been 
found  that  in  this  situation  the  longitudinal  muscular  bundles  are  thinner 
than  elsewhere,  and  it  is  assumed  that  the  occurrence  of  a  bulging  at  this 
point  is  favored  by  frequent  gagging,  vomiting,  and  perhaps  by  other  causes — 
i.  e.,  trauma.  The  sac  varies  in  size  from  a  pouch  as  large  as  the  end  of  one's 
finger  to  a  cylindrical  or  pear-shaped  sac  many  inches  in  length,  which  may 
extend  into  the  thorax.  The  pouch  is  lined  by  mucous  membrane,  which 
may  be  eroded  or  ulcerated  from  prolonged  irritation  and  pressure  from  its 
contents  of  decomposing  food.  A  more  or  less  complete  investment  of  muscular 
fibers  surrounds  the  sac.  The  pouch  usually  forms  on  the  left  side  and  hangs 
down  alongside  of  or  behind  the  gullet  a  variable  distance.  The  orifice  in 
the  gullet  may  be  as  large  as,  larger  or  smaller  than,  the  caliber  of  the  gullet 
itself. 

Usually  no  symptoms  are  produced  until  the  pouch  has  reached  a  consid- 
erable size,  so  that  food  is  retained  in  it.  As  a  further  increase  takes  place, 
the  pressure  of  the  distended  sac  tends  to  keep  the  normal  orifice  of  the  gullet 
closed,  thus  producing  dysphagia.  The  symptoms  are  slowly  developed.  They 
vary  in  different  cases.  The  patient  usually  has  some  difficulty  in  swallowing 
hard,  soft,  or  liquid  food,  as  the  case  may  be.  He  has  a  sensation  of  pressure 
and  discomfort  in  the  neck  while  eating  and  after.  He  may  learn  to  eat 
slowly  and  with  the  head  in  a  certain  position,  or  to  make  certain  movements 
while  eating,  or  to  press  with  his  finger  upon  some  fixed  point  in  the  neck 
during  the  act  of  swallowing.  Sometimes  the  first  few  mouthfuls  are  swal- 
lowed with  difficulty,  later  food  goes  down  readily.  Sometimes  the  condition 
is  reversed.  He  suffers  from  regurgitation  of  considerable  quantities  of  mucus 
into  the  pharynx.  He  vomits  after  eating;  this  vomiting  may  be  simply  a 
regurgitation  of  small  quantities  of  unchanged  food  accomplished  without  much 
effort,  or  there  may  be  quite  violent  gagging  and  retching;  in  either  case  relief 
follows.  Meanwhile  the  appetite  remains  good,  the  patient  has  no  real  gastric 
distress. 

After  a  time  observation  may  show  that  the  vomited  matters  consist  of 
fragments  of  food  eaten  several  days  before ;  such  material  has  a  stinking, 
putrid  odor,  contains  lactic  acid,  but  no  hydrochloric  acid.  The  patient's  breath 
becomes  offensive.  The  time  may  come  when  the  food  distends  the  sac  and 
compresses  the  gullet  in  such  a  manner  that  no  food  enters  the  stomach.  By 
external  pressure  in  the  neck  the  patient  may  be  able  to  empty  the  sac  partly 
or  wholly,  or  by  drinking  water  and  throwing  it  up  again  he  may  wash  its 


DISEASES    OF   THE   ESOFIIAGITS  619 

contents  out,  and  when  it  is  emptied  small  quantities  of  food. may  reach  the 
stomach.  When  this  stage  is  reached  serious  disturbances  of  nutrition  occur. 
Sometimes  the  putrid  contents  of  the  sac  are  regurgitated  and  swallowed 
again ;  if  a  portion  reaches  the  stomach,  indigestion,  fermentative  changes, 
vomiting,  diarrhea,  flatulence,  toxemia  are  added  to  the  other  symptoms.  With 
such  a  history  the  diagnosis  of  a  diverticulum  is  rendered  probable.  A  physical 
examination  shows  the  presence  of  a  swelling  in  the  neck  in  about  half  the 
cases,  and  manipulation  and  pressure  upon  the  swelling  forces  its  contents  into 
the  pharynx. 

Examination  with  bougies  may  give  valuable  information.  WThen  the  sac 
is  full  the  bougie  will  usually  enter  it  rather  than  the  gullet.  The  bougie 
passes  a  certain  distance  easily  and  stops.  The  end  remains  freely  movable. 
The  bougie  may  sometimes  be  felt  in  the  neck,  usually  to  the  left  of  the  middle 
line.  A  subsequent  attempt  to  pass  the  bougie  into  the  stomach  may  succeed. 
If  the  bougie  once  enters  the  true  route  to  the  stomach  it  passes  easily  without 
obstruction.  If  the  bougie  lies  in  the  bottom  of  the  diverticulum,  it  must  be 
withdrawn  the  entire  length  of  the  sac  before  it  can  engage  in  the  orifice  of 
the  gullet  leading  to  the  stomach.  If  the  passage  of  the  bougie  were  opposed 
by  a  mere  fold  of  mucus  membrane,  by  a  symmetrical  dilatation  (ectasia), 
or  by  a  tortuous  canal  through  a  stricture,  a  slight  withdrawal  and  subse- 
quent advance  might  suffice  to  overcome  the  difficulty.  These  characteristics 
serve  to  distinguish  the  condition  from  strictures,  malignant  or  benign.  When 
the  diverticulum  is  well  developed,  it  often  happens  that  the  direct  route  down- 
ward from  the  pharynx  leads  into  the  sac,  while  the  opening  of  the  esophagus 
is  a  mere  slit  or  small  orifice  on  its  anterior  wall;  under  such  conditions  it  is 
necessary  that  the  sac  should  be  emptied  before  a  bougie  can  be  made  to  pass 
into  the  stomach.  In  the  effort  to  enter  the  esophagus  with  a  bougie  the  instru- 
ment should  be  passed  into  the  back  of  the  pharynx  and  the  patient  told  to 
swallow;  the  esophageal  opening  may  then  for  an  instant  become  patent,  and 
the  bougie  may  find  its  orifice.  The  differential  diagnosis  between  dilatation 
and  a  diverticulum  by  means  of  two  tubes,  one  in  the  stomach,  the  other  in 
the  diverticulum  or  dilatation,  has  already  been  mentioned.  By  causing  the 
patient  to  swallow  bismuth  emulsion  the  situation  and  extent  of  a  diverticulum 
might  be  made  out  by  its  skiagraphic  shadow. 

Deep-seated  Diverticula. — Deep-seated  diverticula  from  distention  are 
exceedingly  rare;  a  few  only  have  been  described.  No  tumor  is  formed  in  the 
neck.  The  patients  have  a  sense  of  oppression  after  eating,  vomiting,  which 
occurs  without  nausea  after  eating,  and  may  be  produced  voluntarily  by  clos- 
ing the  larynx  and  bringing  into  action  the  muscles  which  compress  the 
thorax.  There  is  gradually  increasing  dysphagia,  and  finally  disturbances  of 
nutrition.  The  diagnosis  can  sometimes  be  made  with  a  bougie  having  a  tip 
shaped  like  a  catheter  coude  (an  elbowed  catheter).  Such  an  instrument  may 
sometimes  be  made  to  enter  the  stomach  or  the  diverticulum  at  will  by  chang- 
ing the  direction  of  the  curved  tip.     The  character  of  the  vomited  material  is 


620  THE   ESOPHAGUS 

similar  to  that  already  described.  The  X-rays  and  the  two-tube  test  with 
colored  fluids  may  also  give  information,  as  already  mentioned. 

Traction  Diverticula. — Traction  diverticula  have  only  slight  surgical 
interest,  since  they  seldom  produce  symptoms  per  se,  and  are  usually  discov- 
ered at  autopsy.  They  arise  for  the  most  part  from  the  anterior  wall  of  the 
esophagus,  opposite  the  bifurcation  of  the  trachea,  and  are  due  to  cicatricial  con- 
traction of  adhesions  formed  between  the  wall  of  the  gullet  and  inflamed  or 
broken-down  bronchial  glands  the  seat  of  tuberculosis  or  other  inflammatory 
focus.  A  funnel-shaped  pocket  may  thus  be  formed  in  the  wall  of  the  gullet, 
usually  of  small  size,  with  the  apex  of  the  funnel  directed  upward  or  to  one 
side,  rarely  downward.  Evidences  of  a  further  increase  in  size  by  dilatation 
from  within  have  been  observed  in  a  few  cases.  The  surgical  interest  of  the 
condition  is  that  perforation  of  the  gullet  may  take  place  by  ulceration  from 
without  or  by  the  lodgment  and  pressure  of  a  foreign  body  from  within. 
The  diagnosis  of  such  a  diverticulum  might  be  made  through  the  esophago- 
scope. 

New  Growths  of  the  Esophagus. — By  far  the  most  frequent  and  important 
new  growth  occurring  in  the  gullet  is  cancer.  The  symptoms  and  diagnosis  have 
already  been  sufficiently  described.  Of  the  other  new  growths  may  be  men- 
tioned cysts,  papilloma,  fibroma,  myoma,  lipoma,  sarcoma.  They  are  not 
common  tumors,  and  with  the  exception  of  papilloma  and  sarcoma,  rarely  give 
rise  to  symptoms.  Cases  are  on  record  where  large  papillomata  have  formed 
and  have  caused  slight  difficulty  in  swallowing.  The  papillomata  closely 
resemble  cutaneous  warts.  The  diagnosis  could  be  made  through  the  esophago- 
scope  or  by  the  passage  of  a  fenestrated  bougie  and  tearing  off  a  bit  of  the 
papillomatous  growth  for  examination.  Sarcoma  occurs  in  various  forms,  and 
in  the  situations  commonly  the  seat  of  cancer — i.  e.,  at  the  upper  end  of  the 
gullet  and  opposite  the  bifurcation  of  the  trachea.  The  symptoms  are  chiefly 
those  of  obstruction  and  of  hemorrhage,  which  may  be  fatal.  Rupture  into  the 
trachea  is  not  uncommon  in  the  advanced  stages  of  the  disease. 

Polypoid  Growths  of  the  Esophagus. — Polypoid  growths  of  the  esoph- 
agus may  be  fibromata  or  fibromyomata.  They  occur  most  commonly  at  the 
upper  end  of  the  gullet,  and  grow  from  the  posterior  wall  occasionally  at  lower 
levels.  They  are  rare  tumors.  If  small,  they  give  no  symptoms.  If  large, 
symptoms  occur.  They  have  been  observed  in  men  and  women,  more  often 
in  men,  and  develop  during  middle  age  or  later  in  life.  They  are  usually 
pedunculated  tumors  of  cylindrical  or  elongated  pear  shape,  and  may  reach  a 
considerable  size.  As  they  hang  down  the  gullet,  swallowing  movements  tend 
continually  to  lengthen  the  tumor  by  traction.  The  symptoms  are  moderate  dys- 
phagia, a  sensation  of  the  presence  of  a  foreign  body,  sometimes  a  palpable,  mov- 
able tumor  in  the  neck.  If  they  are  coughed  up  into  the  pharynx,  they  may  over- 
lie the  larynx  and  canse  sudden  choking  and  even  asphyxia.  Compression  does 
not  cause  regurgitation  of  food  into  the  pharynx  (difference  from  diverticula). 
They  may  cause  vomiting  or  a  desire  to  vomit  after  eating.     During  an  act 


DISEASES    OF   THE   ESOPHAGUS  621 

of  vomiting  they  may  he  coughed  up  into  the  pharynx,  and  have  been  observed 

of  such  a  length  that  they  actually  hung  out  of  the  patient's  mouth.  The 
surface  of  the  tumor  is  covered  with  mucous  membrane,  frequently  found 
excoriated  or  even  ulcerated  from  the  constant  mechanical  insults  to  which  it 
is  exposed.  In  those  cases  where  the  tumors  are  not  coughed  up  into  the  phar- 
ynx the  diagnosis  can  he  made  by  means  of  the  esophagoscope.  Ordinarily  the 
diagnosis  is  quite  simple,  and  in  cases  where  the  tumor  habitually  inhabits  the 
pharynx  or  mouth,  can  be  made  on  inspection,  or  by  the  aid  of  the  laryngoscopic 
mirror,  or  by  palpation  with  the  forefinger. 


CHAPTER    XXI 


THE  THORAX 


DEFORMITIES   OF   THE   THORAX 

Deformities   of  the  thorax  may  be   congenital  or   acquired, 
common  types  are  enumerated  below. 


The  more 


Congenital  Deformities  of  the  Thorax 

Deformities  of  the  Sternum. — The  sternum  may  be  congenitally  absent.  The 
space  between  the  ribs  may  be  occupied  by  fibrous  tissue,  or  by  a  thin  mem- 
branous layer  only.     The  bone  may  be  fissured,  the  fissure  being  complete  or 

partial.  There  may  be  one  or  more 
round  or  oval  holes  in  the  bone. 
The  xiphoid  cartilage  may  be  bifid 
or  perforated.  But  one  lateral  half 
of  the  sternum  may  be  developed. 
These  deformities  are  of  no  great 
surgical  interest,  and  their  recogni- 
tion requires  no  description.  The 
defects  of  the  sternum  may  be  ac- 
companied by  hernia  of  the  lung. 
Funnel-shaped  depression  of  the 
lower  part  of  the  sternum  occurs 
as  a  congenital  defect  of  unknown 
causation  and  independent  of  any 
pathological  condition.  The  de- 
formity may  be  slight  or  marked. 
A  typical  case  is  shown  in  the  il- 
lustration (see  Fig.  225). 

Congenital  Defects  of  the   Ribs. 
— There    may    be     supernumerary 

Fig.  225.— A  Congenital  Deformity  of  the  Ster-  r^S.       (See   Cervical  Rib.)       One  or 

num.   Showing   Marked   Funnel -Shaped   Df,  mQre    ribg    m  fo    wantin£r    0r    im- 

pression.      The  countenance  of  the  child  is  also  J  _    ° 

characteristic  of  enlarged  tonsils  and  adenoids  of  perfectly    developed,    ending    anteri- 
the  pharynx  for  which  condition  he  entered  the  L  ° 

hospital.    (New  York  Hospital  collection.)  orly  at  the  axillary  line,  for  exam- 

622 


DEFORMITIES    OF    THE    THORAX 


623 


Fig.  226 — Deformity  of  the  Thorax  Following  Empy- 
ema. (Roosevelt  Hospital,  collection  of  Dr.  Charles  Mc- 
Burney.) 


pie.  When  a  rib  is  wanting, 
the  space  is  occupied  by  a 
more  or  less  dense  layer  of 
fibrous  tissue.  The  diagno- 
sis is  evident  on  palpation, 
sometimes  on  inspection.  If 
the  twelfth  rib  is  wanting, 
the  pleura  might  be  opened 
in  certain  incisions  used  for 
exposing  the  kidney.  One 
or  more  ribs  may  be  fused 
together  or  unite  to  articu- 
late with  but  one  cartilage. 
(See  also  Kidney.) 

Congenital  Defects  of  the 
Muscles  of  the  Thorax. — 
Congenital  defects  of  the 
muscles  of  the  thorax  are 
rare.     The  most  common  is 

absence  or  imperfect  development  of  the  pectoralis  major.     The  clavicular  por- 
tion is  sometimes  absent.     The  pectoralis  minor,  the  serratus  magnus,  and  the 

intercostal  muscles  may  also  be  con- 
genitally  absent.  Such  defects  may 
be  associated  with  absence  of  cer- 
tain ribs,  defects  of  the  sternum, 
and  with  imperfect  development  of 
the  skin  and  underlying  soft  parts. 
Acquired  Deformities  of  the 
Thorax. — Acquired  deformities  of 
the  thorax  may  be  the  result  of 
injury  or  of  disease.  Rachitis, 
scoliosis,  and  Pott's  disease  of  the 
spine,  chronic  bronchitis  and  em- 
physema of  the  lungs,  empyema 
with  collapse  of  the  lung — all  give 
rise  to  more  or  less  typical  deform- 
ities, and  the  same  may  be  said  of 
habitual  tight  lacing  of  stays  among 
young  women.  Rachitic  deformity 
of  the  thorax  is  often  associated 
with  enlarged  tonsils,  adenoids  of 
the  pharynx,  and  deformities  of 
the  nasal  fossa.     The  deformity  is 

Fig.  227. — Deformity  of  the  Thorax  Following  .  ,  »  ,, 

Pott's  Disease.  (New  York  Hospital  Collection.)    .         Sometimes     Spoken    0±     as         pigeon 


624 


THE    THORAX 


breast  "  or  "  chicken  breast,"  "  pectus  carinatum."  The  antero-posterior  depth 
of  the  thorax  is  increased,  the  transverse  diminished,  except  at  its  lower  part. 
(See  Rachitis.)  The  deformity  of  the  thorax  accompanying  chronic  bronchitis 
and  emphysema  consists  in  a  general  expansion  of  the  thorax  by  the  increase 
in  size  of  limgs,  such  that  the  thorax  assumes  almost  a  cylindrical  or  barrel 
shape.  The  deformity  is  qnite  common  among  elderly  laboring  men  who  suffer 
from  chronic  bronchitis.  The  acquired  deformities  accompanying  diseases  of 
the  spine,  etc.,  are  described  under  their  appropriate  headings. 

Hernia  of  the  Lung. — Prolapse  of  the  lung  through  openings  in  the  walls 
of  the  thorax,  the  result  of  trauma,  are  readily  recognizable.     If  the  lung  pro- 


Fig.  228.- 


-Deformity  of  the  Thorax  from  von  Jaksch's  Anemia. 
(New  York  Hospital  Medical  service.) 


trudes  in  an  open  wound,  the  character  of  the  lung  tissue  is  evident  on  inspec- 
tion. Such  lung  tissue  may  be  normal  in  appearance  if  recently  prolapsed. 
If  inflamed,  it  will  be  covered  with  a  fibrino-purulent  exudate  and  hepatized. 
If  strangulated,  it  may  be  gangrenous.  If  the  prolapse  is  subcutaneous,  the 
tumor  is  elastic,  compressible,  can  be  reduced,  with  the  sensation  of  an  emphy- 
sematous crackling,  and  unless  the  lung  is  strangulated,  vesicular  breathing 
may  be  heard  over  it  on  auscultation.  True  hernia  of  the  lung  may  be  con- 
genital or  acquired.  The  congenital  hernia^  are  very  rare.  The  lung  may 
protrude  into  the  neck  alongside  the  trachea,  between  the  ribs  at  the  junction 
of  the  ribs  with  their  cartilages,  through  congenital  defects  in  the  sternum. 
Sometimes  as  a  congenital  defect  the  lung  is  displaced  from  its  normal  situ- 
ation in  part,  and  protrudes  externally  or  internally,  as  into  the  peritoneal 
cavity.  The  condition  is  known  as  ectopia  of  the  lung,  and  is  distinguished 
from  hernia  by  the  fact  that  in  the  latter  a  normally  placed  lung  protrudes 
through  some  normally  weak  place  in  the  thoracic  wall,  which  has  been  fur- 
ther weakened  by  injury  or  disease.  Acquired  hernia  occurs  as  the  result  of 
chronic  bronchitis  and  emphysema,  and  from  violent  spasms  of  coughing,  as 


INJURIES    OF   THE    THORAX   AND   ITS    CONTENTS  625 

in  whooping-cough,  etc.  The  points  of  protrusion  are  the  root  of  the  neck, 
at  the  junction  of  the  ribs  with  their  cartilages,  and  the  intercostal  spaces  in 
front  of  the  thorax. 


INJURIES   OF   THE   THORAX  AND   ITS   CONTENTS 

Subcutaneous  Injuries 

Contusions  of  the  thorax  arise  from  various  kinds  of  blunt  violence ;  blows, 
falls,  and  crushing  injuries  of  all  degrees  of  severity.  So  long  as  the  soft  parts, 
skin,  subcutaneous  tissues,  and  muscles  alone  are  injured,  while  the  wall 
of  the  thorax  and  its  contents  escape,  the  signs  and  symptoms  are  those  of  sim- 
ple contusions  merely — namely,  pain,  soreness,  and  tenderness,  increased  by 
motion  if  the  muscles  are  injured,  together  with  swelling  and  ecchymosis 
due  to  the  presence  of  extravasated  blood.  The  more  serious  injuries  of  the 
thorax,  such  as  follow  "  run-over  "  accidents,  falls  from  a  height,  being  caught 
between  the  buffers  of  railway  cars,  etc.,  are  commonly  attended  by  fractures 
of  the  ribs  and  the  sternum,  and  injuries  of  the  thoracic  contents,  the  lungs 
and  trachea,  the  pleura,  the  heart  and  great  vessels,  the  diaphragm  and  esoph- 
agus. The  injuries  to  the  viscera  may  be  caused  by  the  broken  ends  of  frac- 
tured ribs,  or  the  sternum  or  the  viscera  may  be  crushed  between  the  anterior 
thoracic  wall  and  the  spine  by  simple  compression.  If  the  thorax  is  suddenly 
and  violently  compressed  while  the  glottis  is  closed  the  lungs  may  burst.  The 
thoracic  viscera  withstand  slow  and  gradual  compression  remarkably  well  with- 
out grave  injury.  The  sudden  violent  compressions  are  often  associated  with 
similar  injuries  of  the  abdominal  viscera,  rupture  of  the  liver,  the  stomach, 
intestine,  kidney,  spleen. 

The  organs  most  commonly  injured  are  the  lungs;  their  laceration  is  ac- 
companied by  bleeding,  with  the  production  of  hemothorax,  hemopneumothorax, 
pneumothorax,  and  if  the  parietal  pleura  is  also  torn,  by  subcutaneous  emphy- 
sema. In  these  cases  emphysema  arises  from  fracture  of  ribs  and  laceration  of 
the  pulmonary  and  parietal  pleura.  It  is  easily  recognized  by  the  diffuse  swelling 
and  the  unmistakable  subcutaneous  crackling  on  palpation.  Emphysema  in  the 
tissues  of  the  mediastinum  causes  symptoms  of  compression  of  the  heart,  lungs, 
etc.,  dyspnea,  oppression,  a  rapid  heart,  etc.  Cough  with  expectoration  of 
foamy  blood  is  a  common  symptom.  Depending  upon  the  gravity  of  the  injury 
the  general  symptoms  will  vary  greatly.  After  slight  injuries  the  general 
symptoms  will  be  absent  or  trifling;  in  severe  cases  marked  shock  will  be  pres- 
ent, a  feeble  pulse,  cold,  clammy  extremities,  dyspnea,  cyanosis,  or  paleness  of 
the  face,  hurried,  superficial,  labored  or  irregular  breathing,  and  orthopnea.  A 
very  marked  sign  present  in  many  of  the  most  severe  cases  of  thoracic  compres- 
sion is  a  diffused  dusky  ecchymotic  discoloration  of  the  thoracic  wall  extend- 
ing upward  sometimes  on  to  the  neck  and  face,  and  in  some  cases  accompa- 
nied by  ecchvmosis  into  the  ocular  conjunctiva.  Minute  punctate  hemorrhages 
41 


626 


THE   THORAX 


can  be  seen  in  the  skin  over  some  areas.  The  appearance  somewhat  resembles 
the  post-mortem  discoloration  seen  upon  the  dependent  portions  of  the  body 
some  hours  after  death.  The  sign  indicates  a  very  serious  injury.  If,  in 
addition  to  the  injury  of  the  lung,  the  heart  and  great  vessels  are  crushed  or 
wounded,  the  condition  of  shock  ends  rapidly  in  death.  If  the  injury  to  the 
thoracic  viscera  is  moderate  while  the  abdominal  organs  are  also  ruptured,  the 
abdominal  symptoms  may  be  most  marked. 

If  the  diaphragm  is  ruptured  there  will  be  severe  pain  and  dyspnea  with 
costal  respiration.  A  remarkable  case  of  this  kind  is  shown  in  the  illustration, 
a  drawing  made  at  the  autopsy  of  a  man  who  had  died  some  hours  after  a 
crushing  injury  of  the  thorax.  He  was  brought  to  the  Hudson  Street  Hos- 
pital in  a  condition  of  shock,  from  which  he  did  not  rally.  The  stomach  and 
a  considerable  portion  of  intestine  were  found  as  shown  in  the  pleural  cavity, 


Fig.  229. — Rupture  of  the  Diaphragm,  Prolapse  of  the  Stomach  and  a  Portion  of  the  Intestine 
into  the  Pleural  Cavity.     (Hudson  Street  Hospital.)      (Drawing  by  Dr.  B.  S.  Barringer.) 

where  they  had  found  their  way  through  the  ruptured  diaphragm.  The  con- 
dition was  not  suspected  during  life.  Cases  of  this  kind  have  survived  for 
long  periods,  the  condition  only  being  recognized  at  autopsy.  In  other  cases 
death  has  followed  the  introduction  of  an  aspirating  needle  into  the  hollow 
abdominal  viscera,  contained  in  the  thorax,  for  purposes  of  exploration,  the 
physical  signs  being  those  of  pneumothorax.  The  degree  of  subcutaneous 
emphysema,  common  enough  in  cases  of  extensive  rupture  of  the  lung  and 


INJURIES    OF   THE   THORAX   AND   ITS   CONTENTS 


627 


pleura,  is  well  shown  in  the  accompanying  illustration  of  a  man  who  was 
crushed  in  an  elevator  shaft,  both  lungs  were  ruptured  and  several  ribs  frac- 
tured ;  his  body  showed  the 
peculiar  discoloration  al- 
ready mentioned.  He  lived 
saveral  days,  suffering  from 
shock,  cyanosis,  and  dysp- 
nea, with  bloody  expecto- 
ration. The  emphysema 
continually  increased.  The 
photograph  was  made  about 
four  hours  before  death. 

Physical  Signs. — Pneu- 
mothorax, hemothorax,  he- 
mopneumothorax,  and  their 
combination,  give  the  phys- 
ical signs  of  these  condi- 
tions— namely,  the  affected 
side  of  the  chest  is  enlarged 
and  is  more  or  less  com- 
pletely immobile.  The 
heart  impulse  is  displaced. 
Vocal  fremitus  is  greatly 
diminished  or  abolished. 
Percussion  over  the  affect- 
ed side  usually  gives  a 
high-pitched  tympanic  note, 
very  rarely  flatness  or  dull- 
ness. If  blood  be  also  pres- 
ent, as  is  usually  the  case,  there  will  be  flatness  or  dullness  up  to  the  level  of  the 
fluid ;  by  changing  the  position  of  the  patient  this  dullness  may  change  its  posi- 
tion. On  auscultation  there  is  absence  of  breathing,  or  very  feeble  breathing 
over  the  affected  side;  the  respiratory  sounds  on  the  uninjured  side  are  loud  and 
exaggerated.  On  coughing  or  taking  a  deep  breath  the  sound  known  as  metallic 
tinkle  may  be  present ;  the  voice  often  has  a  peculiar  metallic  quality.  The 
coin  sound  is  sometimes  present.  It  is  elicited  in  the  following  manner :  The 
surgeon  places  his  ear  on  the  patient's  thorax  posteriorly  while  an  assistant 
holds  a  coin  on  the  skin  of  the  front  of  the  chest  and  strikes  it  with  another 
coin.  A  characteristic  metallic  echoing  sound  is  thus  produced,  which  is  unmis- 
takable. In  the  presence  of  fluid  the  succussion  or  splashing  sounds  may  be 
heard  by  placing  the  ear  against  the  thorax  and  shaking  the  patient.  This 
sound  may  sometimes  be  heard  by  the  patient  himself,  or  be  audible  to  bystand- 
ers. The  abdominal  viscera  may  be  displaced  downward,  so  that  the  upper 
border  of  liver  dullness  is  displaced  even  as  low  as  the  costal  margin  in  front. 


Fig.  230.  —  Subcutaneous  Emphysema  from  Fracture  of 
Several  Ribs,  Rupture  of  Both  Lungs.  (Author's  col- 
lection.) 


628 


THE   THOEAX 


Subphrenic  Pneumothorax  and  Subphrenic  Pyopneumothorax. — An  accumula- 
tion of  gas  or  of  gas  and  pus  between  the  liver  and  the  diaphragm  may  simu- 
late true  pneumothorax.     Such  a  collection  may  form  as  the  result  of  traumatic 

or  pathological  perforation  of  the 
hollow  viscera  of  the  abdomen,  or 
might  accompany  a  subphrenic  ab- 
scess from  any  cause  if  gasogenic 
bacteria  were  present  in  the  exu- 
date. It  will  rarely  happen  in 
traumatic  cases  that  the  condition 
simulates  a  pneumothorax  so  close- 
ly as  to  lead  to  diagnostic  error. 
The  signs  of  peritonitis — pain,  ab- 
dominal rigidity,  vomiting,  etc. — 
together  with  the  history  of  the 
injury,  will  usually  point  definite- 
ly to  an  abdominal  origin.  The 
differential  points  are  as  follows: 
History  of  an  abdominal  injury 
or  disease,  absence  of  cough,  ex- 
pectoration, and  dyspnea ;  absence 
of  marked  displacement  of  the 
heart ;  the  presence  of  normal  or 
nearly  normal  breathing;  voice 
and  vocal  fremitus  over  the  upper 
portion    of    the    thorax.      A    sharp 

Fig.  231.  — Deformity  of  the  Thorax  Following       line      of      demarcation      above,      be- 

sSon.)'    (NeW  Y°rk  H°Spita1,  ""^  °f  L'  A      tween    the    normal    hmg   resonance 

and  the  tympanitic  resonance  be- 
low, normally  occupied  by  liver  dullness ;  marked  displacement  of  the  liver 
downward.  Over  the  tympanitic  area  below;  absence  of  voice  and  vocal 
fremitus.  (For  further  discussion,  see  Diseases  of  the  Abdomen.)  In  using 
an  aspirating  needle  for  the  determination  of  the  presence  of  blood  or  pus 
in  the  pleural  cavity,  it  is  to  be  borne  in  mind  that  serous  or  purulent  fluid 
and  fluid  blood  can  readily  be  drawn  through  a  needle  of  moderate  size.  This 
is  not  true  of  clotted  blood,  which  can  only  be  drawn  through  a  very  large 
needle  or  trocar,  and  that  with  difficulty,  if  at  all,  except  through  a  powerful 
steam  or  compressed-air  exhaust  pump.  A  little  may  be  obtained  usually 
as  a  plug  in  the  interior  of  the  needle,  and  may  suffice  for  a  diagnosis.  It 
is  further  to  be  remembered  that  a  needle  thrust  into  the  lung  may  enter 
a  vein,  and  thus  create  a  possible  error  in  diagnosis.  The  subcutaneous  in- 
juries of  the  lung  are  only  rarely  followed  by  pneumonia  or  by  empyema. 

Commotio  thoracica — Concussion  of  the  Thorax. — Under  this  title  are  de- 
scribed certain  cases  of  sudden  compression  of  the  thorax,   attended  by  the 


INJURIES    OF   THE    THORAX   AND   ITS    CONTENTS  629 

symptoms  of  shock,  sometimes  immediately  fatal,  in  which  no  lesions  of  the 
thoracic  viscera  are  found  to  account  for  the  symptoms.  The  condition  has 
been  accounted  for  in  various  ways — irritation  of  the  pneumogastrics,  paralysis 
of  the  sympathetic,  and  compression  of  the  heart.  The  symptoms  are  those  of 
shock ;  there  is  a  marked  fall  of  blood-pressure ;  coldness  and  paleness  of  the 
surface  of  the  body ;  sometimes  unconsciousness ;  shallow  respiration.  Death 
may  take  place  at  once.  In  case  of  survival,  the  patients  recover  quite  rap- 
idly— in  minutes,  hours,  or  a  day  or  two.  The  signs  and  symptoms  of  lesions 
of  the  viscera  are  absent.  It  is  probable  that  in  many  fatal  cases  lesions  were 
present  but  unrecognized. 

Wounds  of  the  Thorax 

Wounds  of  the  thorax  may  be  divided  into  penetrating  and  nonpenetrating. 

Nonpenetrating  Wounds. — Nonpenetrating  wounds  of  the  thoracic  wall  may 
be  incised,  stab,  punctured,  lacerated,  and  gunshot  wounds.  They  are  rarely 
serious  injuries  unless  infected.  Serious  hemorrhage  is  only  likely  to  occur 
from  injury  of  the  internal  mammary  or  intercostal  arteries.  The  diagnosis 
of  incised  or  contused  and  lacerated  wounds  is  to  be  made  by  inspection.  The 
diagnosis  of  nonpenetrating  stab  and  punctured  wounds  is  to  be  made  from 
the  history  of  the  injury,  the  character  of  the  weapon  producing  it,  the  pres- 
ence or  absence  of  bleeding,  or  the  formation  of  a  hematoma,  and  the  absence 
of  the  signs  and  symptoms  of  injury  of  the  thoracic  viscera. 

Gunshot  Wounds  of  the  Wall  of  the  Thorax. — A  bullet  moving  at  a 
low  velocity  may  produce  a  mere  contusion  of  the  skin  and  subcutaneous  tissues. 
It  may  penetrate  but  a  short  distance  and  remain  palpable  under  the  skin, 
it  may  strike  a  rib  or  the  sternum  and  cause  a  fracture  without  penetrating; 
such  a  fracture  may  wound  the  pleura  and  lung.  The  probable  diagnosis  of 
a  nonpenetrating  wound  can  often  be  made  from  the  absence  of  symptoms. 
One  or  more  X-ray  pictures  may  aid  in  the  diagnosis.  A  peculiar  class  of 
gunshot  wounds  are  those  in  which  the  bullet  strikes  the  chest  wall  and  is 
deflected  by  a  fascial  layer,  a  tendon,  or  a  bone,  and  travels  a  greater  or  less 
distance  along  the  chest  wall  without  penetrating,  to  emerge  or  lodge  at  a 
point  perhaps  opposite  to  the  point  of  entrance,  giving  the  impression  that  it 
has  passed  through  the  chest.  Signs  and  symptoms  of  injury  to  the  viscera 
are  absent.  In  the  absence  of  bleeding,  infection,  or  other  indication  for  inter- 
ference, such  wounds  had  better  be  let  alone ;  nothing  is  to  be  gained  by  explora- 
tion, and  much  harm  may  be  done.  If  exploration  becomes  necessary,  the 
upper  extremity  should  be  placed  in  the  position  it  occupied  when  the  shot  was 
received ;  thus  the  track  of  the  bullet  may  be  more  easily  followed. 

Wounds  of  Vessels. — The  Internal  Mammary  Artery. — The  internal 
mammary  artery  may  be  wounded  in  stab  and  gunshot  wounds.  The  injury  is 
often  associated  with  wounds  of  the  pericardium,  heart,  pleura,  and  lung. 
According  to  the  character  of  the  external  wound  the  bleeding  may  take  place 


630  THE   THOEAX 

externally  or  into  the  mediastinum,  pleura,  or  pericardium,  causing  symptoms 
of  dyspnea,  disturbances  of  the  pulse  from  compression  of  the  heart,  the  signs 
of  hemorrhage,  etc.  The  artery  runs  downward  parallel  with  and  close  to  the 
border  of  the  sternum  from  the  third  intercostal  space  to  the  level  of  the  sixth 
or  seventh  costal  cartilages,  where  it  divides  into  its  terminal  branches  to  the 
anterior  abdominal  wall  and  the  diaphragm.  It  is  usually  accompanied  by 
two  veins.  If  the  bleeding  is  external,  the  diagnosis  is  to  be  made  from  the 
anatomical  site  of  the  wound  and  the  occurrence  of  rapid  arterial  hemorrhage. 
Statistics  of  uncomplicated  wounds  of  the  internal  mammary  treated  by  a 
double  ligation  show  a  mortality  of  over  ten  per  cent.  In  untreated  cases  the 
mortality  has  been  very  high. 

Wounds  of  the  Intercostal  Arteries. — Wounds  of  the  intercostal  arteries, 
though  not  as  dangerous  as  those  of  the  internal  mammary,  may  yet  be  serious 
or  fatal  injuries.  Stab  and  gunshot  wounds  are  the  most  frequent  causes, 
fractures  of  ribs  being  rarely  accompanied  by  bleeding  from  these  vessels. 
The  intercostals  are  often  wounded  during  excision  of  portions  of  ribs,  but 
here  the  control  of  the  bleeding  is  a  simple  matter. 

Wounds  of  the  Pleura  and  Lung. — In  stab  and  gunshot  wounds,  injury 
of  the  pleura  and  lung  are  common.  The  bleeding  may  take  place  externally, 
or  into  the  pleura,  or  both.  If  externally,  it  will  be  brisk  arterial  bleeding. 
If  the  pleura  or  pleura  and  lung  are  also  wounded,  the  blood  may  be  mixed 
with  air,  and  escape  only  during  expiration,  the  blood  and  air  being  sucked 
into  the  pleura  during  inspiration.  Emphysema  may  be  present  around  the 
wound.  If  the  bleeding  occurs  into  the  pleural  cavity,  there  will  be  signs  of 
hemo-  or  hemopneumothorax,  dyspnea,  and  the  symptoms  of  hemorrhage.  Such 
bleeding  may,  of  course,  come  from  a  wounded  lung.  If  there  is  reason  to 
suspect,  from  the  character  and  situation  of  the  wound,  that  dangerous  hemor- 
rhage is  going  on  from  an  intercostal  artery,  the  diagnosis  should  be  confirmed 
by  enlarging  the  wound,  resecting  a  rib,  if  necessary,  in  order  that  a  ligature 
may  be  properly  applied  to  the  vessel. 

Penetrating  Wounds  of  the  Thorax. — Penetrating  wounds  of  the  thorax  may 
involve  the  pleura,  the  lung,  the  pericardium  and  heart,  the  great  vessels,  the 
trachea  and  esophagus,  and  the  diaphragm.  Wounds  of  the  costal  pleura  alone 
occur  from  fractured  ribs.  If  uncomplicated,  the  injury  is  rarely  attended  by 
any  symptoms  other  than  pain,  cough,  and  a  little  dry  pleurisy,  which  may  be 
recognized  by  fine  friction  rales  heard  on  auscultation  over  the  injury.  The 
occurrence  of  subcutaneous  emphysema  over  a  simple  fracture  of  a  rib  indi- 
cates an  injury  of  the  lung.  Open  wounds  of  the  thorax  may  be  incised,  stab 
or  gunshot  wounds ;  less  commonly  they  are  lacerated  wounds ;  these  latter  are 
commonly  caused  by  great  degrees  of  violence ;  such  have  been  caused  by  a 
blow  of  the  paw  of  a  powerful  wild  beast — a  bear,  a  lion,  tiger,  etc. — or  from 
crushing  injuries.  Penetrating  wounds  involving  the  costal  pleura  alone  are 
less  common  than  wounds  both  of  the  pleura  and  lung.  In  some  cases  it  may 
be  impossible  to  tell  whether  the  lung  is  wounded  or  not.     The  presence  of 


INJUEIES    OF   THE   TIIOEAX   AXD   ITS    CONTEXTS 


631 


cough  with  bloody  or  rusty  sputum  indicates  that  the  lung  has  been  wounded. 
Wounds  at  the  lower  limits  of  the  pleural  cavity  may  open  the  pleura  without 
injuring  the  lung.  The  following  figures  indicate  the  positions  of  the  border 
of  the  lung  and  of  the  limit  of  the  pleural  sac  in  different  parts  of  the  chest 
during  quiet  breathing.  It  will  thus  be  seen  that  a  considerable  space  exists 
between  the  edge  of  the  lung  and  the  bottom  of  the  costophrenic  sinus ;  the 
space  is  greatest  in  the  axillary  line. 

The  table  is  a  personal  communication  from  Prof.  George  S.  Huntington. 


Sternal  line. 

Parasternal 
line. 

Mammillary 
line. 

Axillary  line 

Costovertebral 
line. 

Level  of  lower  bor- 
der of  lung 

Upper  bor- 
der of 
sixth  rib 

Lower  bor- 
der of 
sixth  rib 

Upper  bor- 
der of 
seventh  rib 

Lower  bor- 
der of 
seventh  rib 

Eleventh  rib 

Lower    limit    of 
pleura 

Upper  bor- 
der of 
seventh  rib 

Middle  of 
seventh  rib 

Lower  bor- 
der of 
seventh  rib 

Ninth  rib 

Twelfth  rib 

Difference  in  verti- 
cal    height     be- 
tween  lung   and 
pleura 

2  centi- 
meters 

2  centi- 
meters 

2  centi- 
meters 

6  centi- 
meters 

2.5  centi- 
meters 

Wounds  of  the  Pleura. — Wounds  which  penetrate  the  pleura  in  a  tan- 
gential or  oblique  direction  are  less  likely  to  penetrate  the  lung  than  those 
which  penetrate  at  right  angles.  When  the  pleura  is  opened,  air  enters  the 
pleural  cavity  in  greater  or  less  quantity,  according  to  the  size  and  shape  of 
the  opening.  If  the  opening  is  free,  much  air  enters,  the  lung  collapses  com- 
pletely, and  ceases  to  functionate.  Adhesions  between  the  lung  and  parietal 
pleura  prevent  its  collapse  to  a  variable  extent.  If  the  wound  canal  is  small 
or  oblique,  no  air  may  enter  from  without.  When  the  pleura  is  filled  with  air, 
that  side  of  the  chest  is  distended,  and  the  heart  and  the  other  lung  are  com- 
pressed. 

The  symptoms  produced,  by  complete  sudden  collapse  of  the  lung  vary  in 
gravity  in  different  cases :  some  patients  show  intense  dyspnea,  orthopnea 
(the  breathing  is  largely  diaphragmatic),  cyanosis;  have  a  rapid,  thready  pulse. 
The  physical  signs  are  immobility  and  distention  of  the  chest  on  the  injured 
side.  Tympanitic  resonance  over  that  side  of  the  chest  and  absence  of  breath- 
ing or  very  feeble  respiratory  sounds  on  auscultation  (pneumothorax).  The 
condition  may  end  in  death,  from  failure  of  the  heart  or  respiration.  The 
symptoms  are  likely  to  be  more  severe  when  the  pneumothorax  is  on  the  right 
side.  The  entrance  of  air  through  an  open  wound  takes  place  during  inspira- 
tion, and  is  accompanied  by  a  loud  blowing  or  whistling  sound.  During  expi- 
ration some  air  escapes,  but  less  than  has  entered  during  inspiration.  If  the 
wound  remains  open,  air  continues  to  enter  until  the  lung  is  completely  col- 
lapsed.    If  the  wound  is  large,  and  especially  if  it  be  near  the  border  of  the 


632 


THE   THORAX 


lung,  prolapse  of  lung  tissue  may  take  place  during  expiration.  If  both  pleural 
sacs  are  opened  and  both  lungs  collapse  immediate  death  occurs.  It  is  worth 
remembering  that  in  cases  of  large  abscess  in  the  right  lobe  of  the  liver,  when 
pressure  and  infiltration  hold  the  right  half  of  the  diaphragm  nearly  or  quite 


Fig.  232.  —  Showing  the  Relations  of  the 
Lungs  and  of  the  Lower  Limit  of  the 
Pleura  to  the  Ribs.  Thorax  viewed  from 
in  front.     (After  Merkel.) 


Fig.  233.  —  Showing  the  Relations  of  the 
Lungs  and  of  the  Lower  Limit  of  the 
Pleura  to  the  Ribs.  Thorax  viewed  from 
behind.      (After  Merkel.) 


immobile,  the  pleural  sac  may  be  entered  in  the  axillary  line,  for  the  purpose 
of  evacuating  the  liver  abscess,  with  scarcely  any  risk  of  creating  a  pneumo- 
thorax. The  pressure  of  the  abscess  holds  the  costal  and  the  diaphragmatic 
pleura?  quite  firmly  in  contact  below  the  border  of  the  lung,  so  that  the  surfaces 
remain  in  contact  when  the  pleura  is  opened  without  the  aid  of  sutures,  even 
though  no  inflammatory  exudate  is  present  on  the  pleural  surfaces.  The 
symptoms  of  collapse  of  one  lung  are  not  always  grave.  During  operations 
the  pleura  is  often  opened  by  design,  sometimes  by  accident.  The  symptoms 
may  be  slight  and  temporary.  It  is  true  that  in  empyema  the  affected  lung 
is  already  partly  deprived  of  its  function,  and  that  in  accidental  wounds  of 
the  pleura  during  operations  the  surgeon  usually  succeeds  in  closing  or  plugging 
the  opening  before  complete  collapse  of  the  lung  has  occurred.  If  no  infec- 
tion takes  place,  and  no  dangerous  amount  of  bleeding  occurs  into  the  pleura 
and  the  wound  is  closed,  the  subsequent  history  of  pneumothorax  is  usually 
favorable;  the  air  and  even  blood  may  be  quite  rapidly  absorbed.  In  a  day 
or   two  the  lung  may  begin  to  expand    and   resume  its  functions,      A   long 


INJURIES    OF    THE    THORAX   AND   ITS    CONTENTS  633 

delay  or  the  accumulation  of  much  blood  in  the  pleura  points  to  a  wound  of 
the  lung ;  often  to  a  wound  of  a  bronchus.  In  these  cases  the  collapsed  con- 
dition of  the  lung  may  be  more  or  less  permanent,  and  that  without  serious 
impairment  of  health. 

Infection  of  Wounds  of  the  Pleura. — Infection  of  wounds  of  the  pleura 
occurs  from  stab  and  incised  wounds  made  with  unclean  instruments,  and  is 
especially  common  when  an  infected  foreign  body  remains  in  the  wound,  a 
splinter  of  wood,  a  portion  of  a  knife  blade  or  dagger,  an  arrowhead,  a  bullet, 
or  a  portion  of  clothing.  As  stated  under  gunshot  wounds,  many  bullet  wounds 
of  pleura  and  lung  run  an  aseptic  course.  Infection  is  further  favored  by  accu- 
mulation of  blood  in  the  pleura  ;  it  may  be  pyogenic,  putrefactive,  or  both.  The 
general  symptoms  are  those  of  sepsis  or  pyemia.  Locally,  a  rapid  exudation 
takes  place  into  the  pleural  sac.  The  patient  suffers  from  dyspnea,  and  a  rapid, 
feeble  heart.  The  thorax  on  the  affected  side  is  distended  ;  the  intercostal  depres- 
sions are  obliterated ;  the  chest  on  that  side  does  not  take  part  in  the  respiratory 
movements.  If  the  exudate  is  large  in  amount,  the  heart  is  displaced  toward 
the  other  side,  and  the  sound  lung  is  compressed.  There  is  flatness  on  percussion 
up  to  the  level  of  the  fluid,  absence  of  voice  and  breathing  on  auscultation,  and 
absence  of  vocal  fremitus  (empyema).  If  air  and  pus  are  present,  the  signs 
are  the  same  as  those  described  under  hemopneumothorax.  The  introduction 
of  an  aspirating  needle  into  the  thorax  below  the  level  of  the  fluid  withdraws 
pus  or  broken-down  and  putrid  blood  clot,  as  the  case  may  be.  Unrelieved  by 
suitable  drainage,  these  cases  end  in  death  from  sepsis,  with  heart  and  respira- 
tory failure  from  compression,  or  pyemia. 

Wounds  of  the  Lung. — Gunshot  and  stab  wounds  are  the  common  forms 
of  wounds  of  the  lung.  Much  less  common  are  impalement  on  stakes,  pickets, 
etc.,  in  falls  from  a  height,  arrow  wounds,  contused  and  lacerated  wounds  from 
crushing  injuries,  or  from  portions  of  exploded  shell  in  battle.  The  gravity  of 
wounds  of  the  lung  depends  chiefly  on  two  things — hemorrhage  and  infection. 
The  diagnosis  is  often  entirely  simple;  rarely  very  difficult.  Positive  signs  of 
wounds  of  the  lung  are,  in  the  presence  of  a  wound  of  the  thoracic  wall,  cough, 
and  bloody,  usually  foamy,  expectoration,  a  nearly  positive  sign,  but  absent 
in  a  certain  proportion  of  even  severe  injuries,  and  the  escape  of  a  foamy  blood 
from  the  external  wound.  The  cough  is  usually  frequent,  harassing,  and 
painful ;  the  patient  strives  to  suppress  it  all  he  can.  In  addition  there  may 
be  present  pneumothorax,  or  pneumohemothorax,  air  rushing  in  and  out  of 
the  external  wound,  emphysema  of  the  chest  wall  in  the  neighborhood  of  the 
wound,  especially  of  the  external  wound,  is  small  or  oblique,  so  that  a  valve- 
like closure  of  the  pleura  prevents  the  entrance  of  air  from  without.  Very 
extensive  emphysema  also  speaks  for  a  wound  of  the  lung.  If  the  lung  is 
adherent  to  the  chest  wall  at  the  wounded  area,  there  may  be  no  pneumothorax, 
but  very  extensive  emphysema,  which  may  spread  over  the  entire  body  in  a  few 
hours.  If  such  emphysema  extends  into  the  mediastinum,  it  may  cause  fatal 
dyspnea  from  compression  of  the  viscera. 


634  THE   THOEAX 

I  saw  a  case  of  this  kind  during  the  time  when  I  was  acting  as  interne 
in  Beilevue  Hospital.  A  man  was  brought  to  the  hospital  who  had  been 
stabbed  in  the  right  axilla.  There  were  no  signs  of  dangerous  external  or 
internal  bleeding,  nor  of  marked  hemo-  or  pneumothorax,  but  a  rapidly  pro- 
gressive subcutaneous  emphysema,  which  involved  almost  his  entire  body  in  a 
few  hours,  and  reached  enormous  proportions.  As  the  emphysema  grew  more 
and  more  marked  at  the  root  of  the  neck  he  began  to  suffer  more  and  more 
from  dyspnea  and  oppression  in  breathing,  gradually  his  heart  failed,  and 
he  died  in  forty-eight  hours  from  the  time  of  receiving  the  wound.  At  the 
autopsy  a  moderate  amount  of  air  and  blood  were  found  in  the  right  pleura ; 
there  was  a  fairly  deep  stab  wound  of  the  right  lung.  The  subcutaneous  tissues 
throughout  the  body  were  emphysematous,  and  the  distention  of  the  loose 
tissues  of  the  mediastinum  with  air  was  especially  marked.  Particles  of  for- 
eign material  may  be  coughed  up — shreds  of  clothing,  for  example — after  gun- 
shot wounds.  Dyspnea,  which  may  be  severe,  moderate,  or  not  noticeable, 
depending  largely  upon  the  presence  or  absence  of  pneumothorax  and  upon 
the  amount  of  bleeding  into  the  pleura  or  into  the  trachea.  The  nearer  the 
wound  is  to  the  root  of  the  lung,  the  more  likely  the  occurrence  of  fatal  bleed- 
ing. When  a  large  vessel  at  the  root  of  the  lung  is  wounded,  the  blood  may 
fill  the  trachea  and  cause  immediate  death  from  asphyxia  or  severe  dyspnea 
with  profuse  hemoptysis,  which  may  continue  until  death,  or  recur  at  intervals 
with  a  finally  fatal  result.  The  symptoms  of  internal  bleeding  into  the  pleura 
are  coldness  and  paleness  of  the  face  and  extremities,  sometimes  cyanosis, 
marked  dyspnea,  and  a  sense  of  oppression,  thirst,  convulsions,  a  rapid,  feeble 
pulse,  finally  syncope,  dilated  pupils,  and  death.  Nearly  all  wounds  of  the 
lung  are  accompanied  by  some  bleeding  into  the  pleura  unless  the  lung  is 
adherent  to  the  thoracic  wall  at  the  point  of  wounding.  But  in  gunshot 
wounds,  especially,  pneumothorax  is  often  slight,  unless  a  bronchus  is  wounded. 

A  boy,  aged  ten,  was  accidentally  shot  in  the  thorax  with  a  .32  caliber  pistol. 
The  bullet  entered  in  the  posterior  axillary  line  in  the  sixth  intercostal  space 
and  ranged  inward,  wounded  a  large  vessel  at  the  root  of  the  lung  and  one 
of  the  primary  bronchi.  He  ran  a  few  paces  and  fell.  He  was  found  in  a 
condition  of  shock,  suffering  from  severe  dyspnea  and  profuse  hemoptysis ;  in 
fifteen  minutes  he  was  dead.  In  other  cases,  if  the  wound  involves  no  large 
vessel  and  infection  is  absent,  the  symptoms  may  be  slight.  A  man  walked 
into  Beilevue  Hospital  in  apparent  good  health.  He  stated  that  he  had  been 
shot  in  the  left  breast  the  preceding  night  with  a  .32  caliber  pistol.  Examina- 
tion showed  a  bullet  wound  in  the  second  intercostal  space  in  the  midclavicular 
line  on  the  left  side.  There  was  no  wound  of  exit.  There  was  slight  em- 
physema in  the  immediate  vicinity  of  the  wound.  He  complained  of  a  painful 
cough,  which  he  endeavored  to  suppress.  His  sputum  was  foamy  and  blood- 
stained. Physical  examination  showed  normal  resonance  everywhere  over  the 
chest  except  a  small  area  of  dullness  beneath  the  wound.  Auscultation  showed 
diminished  breathing  over  the  same  area,  elsewhere  normal.     There  were  dry 


INJURIES    OF   THE    THORAX   AND   ITS    CONTENTS  635 

pleuritic  friction  rales  over  the  upper  lobe  of  the  left  lung  in  front.  He  devel- 
oped no  further  symptoms,  and  left  the  hospital  in  ten  days  quite  well.  In 
recent  wars  fought  with  small-caliber  rifles  it  has  been  observed  that  while 
many  wounds  of  the  lung  are  immediately  fatal  from  internal  hemorrhage, 
those  in  which  no  large  vessel  is  divided  nor  large  bronchus  opened  get  well 
in  many  instances  without  very  serious  symptoms.  If  not  probed,  the  wound 
usually  remains  aseptic.  Wounds  from  the  small-calibered  rifles  are  often  per- 
forating and  pursue  a  straight  course  through  the  tissues,  so  that  a  wound 
of  the  lung  can  often  be  inferred  on  anatomical  grounds  alone.  The  prognosis 
in  these  cases  is,  other  things  being  equal,  rather  better  than  in  cases  of  lodg- 
ment, since  sometimes  such  a  bullet  may  be  the  center  of  a  focus  of  infection 
which  does  not  declare  itself  for  some  time.  The  characters  and  effects  of 
bullet  wounds  from  various  kinds  of  weapons  have  been  described  in  the  chapter 
on  Gunshot  Wounds.  The  small-caliber  rifle  bullet  does  not  produce  very 
destructive  effects  upon  lung  tissue ;  the  track  of  the  bullet  is  small  and  clean, 
unless  the  bullet  is  deformed  by  ricochet  or  strikes  sideways.  Hemoptysis  is 
usually  present,  but  moderate.  Emphysema  may  be  absent  or  slight,  and  is 
usually  confined  to  the  vicinity  of  the  wound.  The  orifices  are  so  small  that 
air  does  not  enter  the  pleura  from  without.  Hemothorax  is  usually  moderate. 
In  some  cases  the  bleeding  has  continued  slowly  for  several  days  or  has  re- 
curred at  intervals,  notably  in  those  cases  where  the  patients  had  to  be  moved 
about  under  unfavorable  conditions.  In  direct  shots,  foreign  bodies  are  rarely 
carried  into  the  wound,  and  if  the  wounds  are  not  explored,  infection  is  the 
exception.  Associated  injuries,  especially  of  vessels,  of  course,  change  the 
prognosis  for  the  worse.  The  location  of  bullets  in  the  cavity  of  the  thorax 
is  generally  practicable  by  means  of  the  X-rays.  Their  removal  is,  however, 
another  matter. 

Infection  of  Wounds  of  the  Lung. — Infection  of  wounds  of  the  lung  occurs 
for  the  most  part  through  the  wound  in  the  thoracic  wall,  very  rarely  through 
the  inspired  air  in  the  lung  itself.  Infection  is  caused  by  bacteria  introduced 
into  the  wound  at  the  time  of  the  injury  by  the  weapon  or  missile  or  by  a 
foreign  body  driven  into  the  tissues — a  button,  a  portion  of  clothing,  of  a 
leather  strap  worn  across  the  shoulder,  etc. — or  is  introduced  afterwards  by 
manipulations  with  unclean  fingers  or  instruments  or  unclean  materials  applied 
to  the  wound.  Infection  is  favored  by  much  contusion  and  laceration  of  tissue 
of  the  thorax  or  of  the  lung  itself  such  as  occurs  in  some  gunshot  wounds, 
notably  those  produced  by  a  soft-lead  rifle  bullet,  or  by  a  bullet  which  fractures 
a  rib  and  drives  fragments  of  bone  into  the  lung.  The  results  of  such  infection 
may  be  suppuration  merely  of  the  external  wound,  more  commonly  empyema, 
purulent  or  putrid  septic  pneumonia,  abscess  of  the  lung,  gangrene  of  the  lung. 
An  abscess  of  the  lung  or  an  empyema  may  perforate  in  various  directions  out- 
ward through  the  thoracic  wall,  into  the  lung  or  a  bronchus,  into  one  of  the 
great  vessels,  downward  into  the  abdomen,  producing  an  abscess  or  a  purulent 
peritonitis,  or  more  rarely  into  the  stomach  or  intestine.     The  signs  and  symp- 


636  THE   THOEAX 

toms  of  empyema  have  already  been  described.  The  diagnosis  of  septic  pneu- 
monia rests  upon  the  presence  of  the  signs  of  a  lobular  pneumonia,  rapid 
breathing  and  pulse,  pain,  cough,  mucopurulent  sputum,  together  with  the 
general  symptoms  of  sepsis.  The  diagnosis  of  abscess  of  the  lung  rests  upon 
the  presence  of  similar  signs  and  symptoms,  together  with  the  expectoration 
of  large  quantities  of  pus,  sometimes  containing  blood  and  fragments  of  lung 
tissue.  The  diagnosis  of  gangrene  of  the  lung  is  to  be  made  from  the  signs  and 
symptoms  of  an  area  of  consolidation  in  the  lung,  the  general  symptoms  of 
sepsis  together  with  cough  and  the  expectoration  of  a  purulent  or  bloody  spu- 
tum having  a  horrible,  putrid  odor,  and  sometimes  containing  black  fragments 
of  gangrenous  lung  tissue.  The  breath  also  is  stinking  and  fetid  to  a  degree. 
For  the  details  of  diagnosis  of  these  conditions  the  reader  is  referred  to  Surgi- 
cal Diseases  of  the  Lungs.  The  occurrence  of  infection  is  to  be  inferred  from 
the  advent  of  fever  of  a  septic  type.  Moderate  fever  is  commonly  present  in 
cases  of  hemothorax,  though  they  remain  aseptic.  (See  Aseptic  Wound  Fever.) 
Dyspnea,  increase  of  pain  and  cough,  prostration,  a  rapid  pulse,  a  rapid  in- 
crease of  the  fluid  exudate  in  the  pleura  indicate  infection.  The  presence  of 
pus  or  putrid  blood  clot  in  the  pleura  can  usually  be  demonstrated  with  an 
aspirating  needle  thrust  into  the  cavity  below  the  level  of  the  fluid.  In  ordi- 
nary cases  the  needle  may  be  introduced  in  the  back  in  the  seventh  or  eighth 
intercostal  spaces  or  in  the  axillary  line  between  the  fifth  and  sixth  ribs.  It  is 
not  wise  to  choose  the  very  bottom  of  the  pleural  cavity  for  the  point  of  inser- 
tion, since  the  diaphragm  or  the  abdominal  viscera  might  be  wounded.  If  the 
exudate  is  encapsulated  or  if  an  abscess  of  the  lung  is  suspected,  the  needle 
is  introduced  wherever  the  physical  signs  are  most  marked.  The  following 
histories  illustrate  the  course  of  an  infected  gunshot  wound  of  the  lung,  and 
of  another  which  remained  clean.  The  second  case  is  interesting  on  account 
of  the  long  duration  of  a  pneumothorax. 

In  the  year  1885  A.  B.,  a  large,  vigorous-looking  Swedish  man,  aged 
thirty-eight  years,  who  had  acute  gonorrhea  and  felt  that  life  under  such  pain- 
ful circumstances  was  no  longer  desirable,  shot  himself  in  the  left  breast  with 
a  .38  caliber  pistol.  He  was  seen  by  a  physician,  who  probed  the  wound  and, 
for  reasons  best  known  to  himself,  applied  to  it  a  portion  of  chewing  tobacco 
which  had  already  fulfilled  its  proper  function,  covering  this  with  a  neat 
bandage.  On  admission  to  the  hospital,  a  bullet  wound  was  found  in  the  fourth 
intercostal  space  on  the  left  side  just  external  to  the  nipple;  there  was  no 
wound  of  exit.  The  wound  did  not  bleed ;  there  was  no  emphysema ;  the 
patient  did  not  suffer  from  shock ;  there  was  a  painful  cough  and  blood-stained 
sputum.  Examination  of  the  left  lung  showed  the  presence  of  a  moderate 
hemothorax.  The  condition  of  the  patient  remained  favorable  until  the  fourth 
day,  when  he  had  a  chill,  a  sharp  rise  of  temperature,  gradually  increasing 
dyspnea.  The  amount  of  fluid  in  the  left  chest,  rapidly  increased.  On  the 
tenth  day  a  portion  of  the  sixth  rib  was  excised  in  the  axillary  line,  the  pleura 
was  opened,  and  a  large  amount  of  pus  evacuated.     The  pleura  was  drained. 


INJURIES    OF   THE    THORAX   AND   ITS    CONTENTS 


637 


Temporary  improvement  occurred,  but  the  lung  did  not  expand.  The  amount 
of  purulent  discharge  from  the  pleura  remained  large.  The  patient  gradually 
failed  in  strength  and  became  emaciated ;  a  daily  rise  of  temperature  occurred. 
After  several  months  a  second  operation  was  done,  and  other  ribs  to  the  number 
of  four  were  extensively  excised.  The  lung  was  found  almost  completely  col- 
lapsed. Following  this  operation  the  patient  gradually  improved.  The  right 
lung  greatly  increased  in  size,  the  left  pleural  sac  became  nearly  obliterated, 
and  the  wound  finally  healed.  The  patient  left  the  hospital  after  many  months 
in  good  health. 

A  young  man  was  shot  with  a  .32  caliber  revolver  in  the  right  chest.  The 
bullet  entered  the  third  intercostal  space  in  the  midclavicular  line.  The  signs 
of  hemopneumothorax  developed  with  collapse  of  the  lung,  though  septic  symp- 
toms did  not  develop.  The  physical  signs  indicated  much  fluid  in  the  pleura. 
Resection  of  a  rib ;  evacuated  a  large  amount  of  fluid  and  clotted  blood  from 
the  right  pleura ;  lung  found  collapsed.  The  external  wound  healed,  but  in 
spite  of  various  measures  used  to  cause  the  lung  to  expand,  pneumothorax 
continued  with  but  little  increase  in  the  size  of  the  lung  for  four  months,  when 
the  patient  passed  out  of  observation. 

Injuries  of  the  Pericardium  and  Heart. — Isolated  injuries  of  the 
pericardium  are  rare ;  in  most  cases  the  heart  is  also  injured,  and  in 
many  the  pleura.  The  injuries 
come  for  the  most  part  from  with- 
out— incised,  stab,  and  gunshot 
wounds — but  may  arise  from  with- 
in, as  from  a  foreign  body  which 
ulcerates  through  the  esophagus,  a 
needle  which  finds  its  way  through 
the  wall  of  the  gullet,  and  the  like. 
Occasionally  the  sharp  end  of  a 
fractured  rib  may  wound  the  peri- 
cardium. The  diagnosis  of  an 
isolated  injury  of  the  pericardium 
may  in  rare  instances  be  simple, 
as  when  a  large  incised  wound  or, 
even  more  rarely,  a  wound  from  a 
shotgun  or  a  shell  fragment,  opens 
the  pericardium  and  lays  the  heart 
bare  to  inspection  or  palpation.     In 

many  instances  it  may  be  difficult  Fig.234.—  Diagram  to  Show  the  Relations  of  the 
ot»    irrmrmqihlp      nnlps^    tliP    sio-nsj     of  Lung  and  the  Complementary  Pleural  Space 

impOSSlDie,     l.nieSS     ine     Signs     OI  TO  the  Chest  Wall.     The  small  triangle  A  rep- 

resents the  area  of  the  pericardium  uncovered  by 
pleura  in  the  average  case.      (After  Merkel.) 


an  exudate  of  some  sort  in  the  peri- 
cardium appear. 

That  portion  of  the  pericardium  which  lies  in  immediate  contact  with  the 
anterior  wall  of  the  thorax  uncovered  by  pleura  is  of  triangular  shape.     (Be 


638 


THE   THOEAX 


it  understood  that  these  limits  vary  greatly.)  Vertically,  this  area  extends 
from  the  level  of  the  junction  of  the  fourth  costal  cartilage  with  the  ster- 
num downward  to  the  level  of  the  junction  of  the  seventh  costal  cartilage 
with  the  sternum.  The  middle  line  of  the  sternum  approximately  forms  one 
side  of  the  triangle  between  these  two  levels.  The  long  side  of  the  triangle 
varies  in  position ;  in  some  cases  it  extends  in  a  line  curved  to  the  left  down- 
ward and  outward,  and  crosses  the  left  border  of  the  sternum  about  at  the 
level  of  the  fifth  costal  cartilage,  and  ends  at  the  level  of  the  seventh  costal 
cartilage  or  opposite  the  junction  of  the  body  of  the  sternum  with  the  xiphoid 
cartilage,  and  distant  from  the  left  border  of  the  sternum  2  cm.  in  about  one 
fifth  of  the  cases  examined.  The  short  side  of  the  triangle  is  a  line  which 
approximates  the  junction  of  the  body  of  the  sternum  with  the  xiphoid  appen- 
dix. The  extent  to  which  the  reflection  of  the  pleura  retreats  to  the  left  varies 
a  good  deal  in  diiferent  cases,  so  that  a  wound  through  a  given  point  might 
open  the  pleura  in  one  case  and  not  in  another.     In  some  instances  the  right 


Fig.  235. — Represents  the  Maximum  Variation  in  the  Position  of  the  Anterior  Borders  of 
the  Pleural  Sac  with  Reference  to  the  Sternum  and  Ribs.      (After  Merkel.) 


pleura  may  even  overlap  the  left  behind  the  sternum.  The  importance  of  these 
relations  is,  that  to  explore  the  pericardium,  a  needle  is  sometimes  introduced 
to  determine  the  presence  and  character  of  an  exudate.  In  order  to  avoid  the 
pleura  with  the  greatest  degree  of  probability,  the  needle  may  be  introduced 
in  the  fifth  interspace  close  to  the  left  border  of  the  sternum,  or  about  an  inch 
external  to  this ;  either  of  these  points  will  avoid  wounding  the  internal  mam- 
mary artery.  Fortunately,  distention  of  the  pericardium  by  an  exudate  pushes 
the  pleura  away  on  either  side  and  increases  the  area  through  which  a  needle 
may  be  introduced  without  injuring  the  pleura.  Such  distention  can  be  out- 
lined by  the  increase  in  the  area  of  heart  dullness.  A  valuable  guide  for  the 
introduction  of  the  needle  is  thus  obtained. 

Symptoms  of  Injuries  to  Pericardium. — The  symptoms  of  wounds  of  the 
pericardium  vary  greatly  in  different  cases.  A  simple  incision  or  puncture 
may  produce  no  symptoms  or  signs,  assuming  that  no  infection  occurs,  except 


INJURIES    OF   THE    THOEAX   AND   ITS    CONTEXTS  639 

some  acceleration  of  the  pulse  rate,  a  dry  friction  sound  over  the  pericardium, 
and  some  localized  dry  pleurisy.  In  healing,  adhesions  are  commonly  formed 
between  pericardium  and  heart.  If,  on  the  other  hand,  hemorrhage  takes  place 
into  the  sac  in  quantity,  very  marked  symptoms  occur.  Such  bleeding  comes 
not  from  the  pericardium,  but  from  the  heart  or  from  the  thoracic  Avail  or  lung. 
The  action  of  the  heart  becomes  tumultuous,  irregular,  rapid,  and  soon  feeble. 
There  is  severe  dyspnea,  and,  unless  relief  is  possible,  these  patients  speedily 
die,  the  heart  being  compressed  by  the  effused  blood  so  that  it  cannot  properly 
expand  in  diastole.  This  condition  of  compression  of  the  heart  by  effused 
blood  was  called  by  Rose  "  tamponade  "  of  the  heart.  The  physical  signs  may 
be  increase  of  heart  dullness  and  a  friction  murmur ;  the  heart  sounds  may 
be  diminished,  absent,  or  normal.  If  the  pleura  and  lung  are  also  wounded, 
air  may  accumulate  in  the  pericardium.  The  heart  dullness  will  then  be  absent 
and  replaced  by  tympanitic  resonance.  A  mixture  of  air  and  blood  may  give 
rise  to  splashing  sounds  on  auscultation  or  to  a  metallic  tinkle.  In  the  presence 
of  hemothorax  or  pneumohemothorax  a  wound  of  the  pericardium  may  pass 
unrecognized.  Infection  of  wounds  of  the  pericardium  gives  rise  to  •purulent 
'pericarditis.  The  signs  and  symptoms  resemble  those  of  hemopericardium, 
with  the  added  general  symptoms  of  sepsis,  high  fever,  sometimes  a  chill.  The 
purulent  exudate  compresses  the  heart.  There  is  rapidly  increasing  dyspnea, 
cyanosis,  a  rapid,  irregular,  and  feeble  pulse,  ending  speedily  in  death  unless 
operative  relief  is  possible.  Some  of  these  cases  are  combined  with  infection 
of  the  pleura  and  empyema,  or  pyopneumothorax.  Pericardial  effusions  tend 
to  accumulate  rather  behind  the  heart  than  in  front  of  it.  The  heart  is  believed 
by  some  observers  to  be  pressed  forward  against  the  chest  wall.  When  intro- 
ducing an  aspirating  trocar  into  the  pericardium  for  diagnostic  purposes  it  is 
important  to  avoid  puncturing  the  heart  or  wounding  the  coronary  artery.  A 
small  trocar  and  cannula  is  safer  than  a  sharp-pointed  aspirating  needle,  al- 
though a  long  hypodermic  needle  is  safe  enough.  The  trocar  is  entered  at  the 
left  border  of  the  sternum  in  the  fifth  intercostal  space,  and  pushed  slowly 
and  carefully  (as  previously  stated,  this  point  is  a  safe  one,  but  another  may 
be  chosen  in  the  particular  case,  the  guide  being  the  limits  and  shape  of  the 
area  of  heart  dullness ;  the  third,  fourth,  fifth,  and  sixth  spaces  have  been  suc- 
cessfully utilized  by  various  surgeons)  obliquely  upward  and  inward;  as  soon 
as  the  point  of  the  instrument  is  believed  to  be  in  the  pericardial  sac,  the  stylet 
should  be  withdrawn.  Some  surgeons  recommend  precautions  against  the  en- 
trance of  air  into  the  pericardium  by  using  a  trocar  with  a  lateral  opening  and 
stopcock,  to  which  a  piece  of  rubber  tube  is  attached,  its  end  immersed  in 
sterile  salt  solution.  Other  surgeons  recommend  the  use  of  a  small  aspirating 
needle,  and  tie  over  its  outer  end  a  sterile  rubber  condom.  The  aspirator  of 
Dr.  Potain  may  be  used.  Inasmuch  as  puncture  of  the  pericardium  is  only  made 
under  very  grave  conditions,  and  for  the  relief  of  pressure  upon  the  heart  by 
serum,  pus,  blood,  air,  or  a  mixture  of  these  materials,  and  the  aspiration  can 
only  be  regarded  as  a  diagnostic  and  palliative  measure,  many  surgeons  prefer 


640  THE    THORAX 

to  resect  the  cartilage  of  the  fifth  rib  on  the  left  side,  thus  gaining  access  to 
the  pericardium  by  an  opening  which  permits  of  subsequent  drainage  of 
the  sac. 

Wounds  of  the  Heart. — Wounds  of  the  heart  may  be  subcutaneous  or  open 
■wounds.  The  subcutaneous  wounds  may  be  produced  by  a  fragment  of  a  frac- 
tured rib  or  the  sternum,  or  they  may  be  ruptures  of  the  heart  from  blunt 
violence,  such  as  occurs  from  sudden  violent  compression  of  the  chest.  The 
heart  may  be  wounded  by  foreign  bodies,  notably  needles  which  have  made 
their  way  to  the  heart  from  a  distance.  Such  foreign  bodies  may  have  been 
in  the  body  for  years  before  they  reached  the  heart.  They  may  cause  serious 
or  fatal  symptoms,  or  in  some  instances  none  at  all.  Sometimes  needles  and 
pins  or  other  bodies  in  the  esophagus  or  trachea  may  perforate  these  structures 
and  reach  the  heart.  Traumatic  ruptures  of  the  heart  may  involve  any  one 
of  its  chambers ;  in  addition,  the  cusps  of  the  valves  may  be  ruptured.  The 
open  wounds  of  the  heart  are  commonly  stab  or  gunshot  wounds ;  less  commonly 
they  are  incised  or  contused  and  lacerated  wounds.  Wounds  of  the  heart 
may  be  superficial  or  penetrating;  the  latter  open  one  or  more  of  the  heart 
cavities.  The  great  majority  of  wounds  of  the  heart  enter  from  in  front, 
much  less  commonly  from  the  side  or  rear. 

Gunshot  wounds  of  the  heart  vary  in  character.  Wounds  made  with  the 
small-calibered  rifle  bullet  will  drill  a  round  hole  through  the  heart  muscle 
without  much  laceration  of  tissue,  or  in  other  cases,  if  the  ball  strikes  the  heart 
in  diastole,  the  heart  may  be  extensively  torn  and  ruptured.  In  the  case  of 
soft-nosed  or  express  bullets  (those  with  a  hollow  point),  the  disintegration 
of  the  heart  muscle,  and  even  of  surrounding  structures,  is  most  extensive;  the 
same  is  true  of  shotgun  wounds  at  short  range.  An  interesting  observation  has 
been  made  in  a  number  of  instances  of  gunshot  wounds  of  the  heart,  namely, 
that  the  heart  may  be  wounded,  even  ruptured,  and  the  valves  torn  by  bullets 
which  do  not  penetrate  the  pericardium.  The  effects  of  wounds  of  the  heart 
are  in  a  large  proportion  of  cases  sudden  death.  The  wounded  individual 
collapses  like  a  steer  when  struck  in  the  forehead  with  a  poleax.  The  heart 
ceases  to  pulsate ;  death  is  immediate.  In  some  cases  even  a  slight  wound 
of  the  heart  is  immediately  fatal  in  this  way.  In  a  good  many  cases,  even  of 
severe  injuries  of  the  heart,  life  is  prolonged  for  minutes,  hours,  or  days,  even 
for  many  days,  though  death  finally  occurs.  A  small  proportion  of  cases  re- 
cover with  or  without  treatment.  In  those  cases  which  survive  for  a  certain 
time,  symptoms  rather  varied  in  character  and  not  very  characteristic  occur. 

The  diagnosis  is  aided  by  the  anatomical  site  of  the  wound,  the  history  of 
the  wounding,  the  character  of  the  weapon,  the  length  of  the  blade,  the  direc- 
tion of  the  wound  canal,  etc.  There  may  be  little  or  no  bleeding  from  the 
external  wound,  if  it  be  small.  If  larger,  the  blood  may  escape  in  rhythmic 
gushes,  and  be  lighter-  or  darker-colored,  according  to  its  source  in  one  or 
other  side  of  the  heart.  Such  blood  may,  of  course,  come  from  an  intercostal, 
the  internal  mammary,  a  coronary  artery,  or  from  the  lung  or  one  of  the  great 


INJURIES   OF   THE   THORAX   AND   ITS    CONTENTS  641 

vessels  of  the  thorax.  Many  cases  of  wounds  of  the  heart  fall  at  once  into  a 
condition  of  profound  shock,  with  syncope.  If  they  rally  and  consciousness 
is  regained,  they  suffer  from  profound  dyspnea  and  precordial  distress.  Bleed- 
ing from  wounds  of  the  heart  may  take  place  externally  or  into  the  pericardium 
or  pleura.  The  expression  of  the  face  is  anxious,  pale  or  cyanotic,  and  the 
forehead  bathed  in  a  clammy  sweat.  The  physical  signs  of  hemo-  or  pneumo- 
pericardium may  be  present,  as  already  described;  respiration  is  extremely 
rapid,  labored,  and  superficial.  The  pulse  is  absent,  or  rapid  and  irregular. 
There  may  be  the  symptoms  of  profuse  hemorrhage,  thirst,  restlessness,  con- 
vulsions, sometimes  vomiting  and  diarrhea.  It  sometimes  happens  that  during 
the  feeble  heart  action  which  accompanies  the  original  syncope  the  bleeding 
from  the  heart  ceases,  only  to  recur  after  minutes,  hours,  or  even  days,  with 
further  syncope  and  death.  These  cases  are  not  out  of  danger  for  a  long  time. 
In  cases  which  recover  from  the  immediate  effects,  serious  lesions  of  the  heart 
muscle,  the  valves,  and  the  endocardium  may  remain,  and  finally  end  the 
patient's  life.  Infection  and  purulent  pericarditis  renders  the  prognosis  much 
worse. 

An  illustration  of  the  manner  in  which  a  wound  of  the  heart  may  produce 
but  few  symptoms  at  first,  and  even  progress  favorably  toward  apparent  recov- 
ery for  some  days,  to  die  quite  suddenly,  came  under  my  observation  some 
years  ago.  A  large,  muscular  man  of  middle  age  shot  himself  with  suicidal 
intent,  and  was  brought  to  the  hospital  a  prisoner.  The  weapon  used  was  a 
.22  caliber  revolver.  There  were  two  wounds,  one  near  the  middle  of  the 
forehead ;  the  skull  was  not  penetrated,  and  the  bullet  could  be  felt  beneath 
the  scalp,  flattened  against  the  bone,  not  far  from  the  wound  of  entrance.  The 
second  wound  was  in  the  third  intercostal  space,  a  half  inch  from  the  left  border 
of  the  sternum.  On  admission  to  the  hospital  the  patient  was  in  moderate 
shock ;  there  was  no  bleeding  from  either  wound.  He  suffered  from  marked 
dyspnea  and  orthopnea.  His  pulse  was  rapid,  feeble,  and  irregular.  ]^o  phys- 
ical signs  pointing  directly  to  a  wound  of  the  heart  were  made  out ;  the  heart 
sounds,  though  weak,  were  present.  His  condition  improved  in  every  way 
during  the  next  twenty-four  hours.  At  the  end  of  this  time  a  slight  increase 
in  heart  dullness  was  noted.  Examination  of  lungs  negative.  He  continued 
to  improve  until  the  fifth  day,  and  was  then  regarded  as  out  of  danger.  On 
this  day,  while  sitting  up  quietly  in  bed,  he  suddenly  fell  back  in  syncope,  and 
in  a  moment  or  two  was  dead.  The  autopsy  showed  a  moderate  amount  of 
recent  blood  clot  in  the  pericardium  and  a  little,  older  blood  clot.  There  was 
a  slitlike  wound  penetrating  the  middle  of  the  wall  of  the  right  ventricle. 
This  wound  was  about  one  half  inch  in  length  and  contained  a  recent  clot. 
The  bullet  was  found  free  in  the  cavity  of  the  right  ventricle. 

There  is  no  certain  method  of  recognizing  the  presence  of  a  foreign  body 
in  the  heart.  After  a  wound  in  which  a  bullet  or  portion  of  a  weapon  re- 
mained in  the  thorax,  its  presence  in  the  heart  might  be  inferred  from  the 

symptoms,  and  the  inference  might  possibly  be  confirmed  bv  an  X-rav  picture. 
42 


642 


THE   THOEAX 


Ruptures  of  the  heart  from  blunt  violence  are  usually  immediately  fatal  in- 
juries. The  following  are  the  principal  mortality  statistics  of  wounds  of  the 
heart :  Loison  found  9  recoveries  among  23  cases  of  needle  Avounds  of  the  heart, 
11  recoveries  among  90  cases  of  stab  wounds,  3  recoveries  among  110  gunshot 
wounds.  The  prognosis  of  stab  wounds  of  the  heart  has  been  improved  by 
recent  successful  operative  treatment.  The  mortality  of  stab  wounds  promptly 
operated  upon  has  been  reduced  to  somewhere  near  sixty  per  cent. 

Injuries  of  the  Great  Vessels  of  the  Thorax. — The  aorta,  pulmonary 
arteries  and  veins,  the  superior  vena  cava,  the  innominate  artery  and  vein,  may 

be  wounded  by  stab  and 
gunshot  wounds,  or  foreign 
bodies  may  ulcerate  through 
the  gullet  and  erode  their 
walls.  Some  of  them  may 
also  be  perforated  by  the 
pressure  of  a  tracheotomy 
tube,  or  opened  by  ulcera- 
tion from  a  neighboring 
purulent  focus.  Unless  the 
opening  is  small  or  incom- 
plete, sudden  death  from 
external  or  internal  bleed- 
ing results.  In  other  cases 
death  may  be  delayed  for 
hours  or  days.  If  the  wound 
is  very  small  or  incomplete, 
an  aneurism  may  form,  and 
rupture  after  a  variable 
period  with  a  fatal  result. 
Wounds  of  these  vessels 
very  rarely  come  under 
treatment  at  all. 

Injuries  of  the  Tho- 
racic Duct. — Injuries  in 
the  cervical  portion  have 
already  been  mentioned.  Injuries  in  the  thoracic  portion  rarely  occur  alone, 
but  are  usually  associated  with  other  and  more  serious  lesions.  Simple  rupture 
of  the  duct  may  lead  to  a  chylous  hydrothorax,  i.  e.,  to  the  accumulation  in  the 
pleura  of  a  greater  or  less  quantity  of  milky  fluid,  and  the  physical  signs  of 
fluid  in  the  pleural  cavity.  The  character  of  the  fluid  is  readily  recognizable 
by  its  gross  appearances  and  the  presence  of  fat  droplets  under  the  microscope. 
Under  normal  conditions  it  coagulates  spontaneously  when  exposed  to  the  air. 
The  presence  of  the  injury,  when  complicated  by  hemothorax  or  other  serious 
lesions,  cannot  be  recognized. 


Fig.  236. — Traumatic  Aneurism  of  the  Subclavian  Artery 
(New  York  Hospital,  &ervice  of  Dr.  Frank  Hartley.) 


INJURIES    OF   THE    THORAX   AND   ITS   CONTENTS  643 

Injuries  of  the  Diaphragm. — Subcutaneous  rupture  of  the  diaphragm 
may  occur  from  severe  crushing  injuries,  and  instances  have  been  recorded 
of  ruptures  as  the  result  of  vomiting  and  during  labor.  The  diaphragm  may 
further  be  wounded  by  stab  and  gunshot  wounds  of  the  abdomen  and  thorax. 
In  most  cases  of  rupture  or  of  wounding,  the  injury  to  the  diaphragm  itself 
is  of  less  consequence  than  the  associated  lesions  of  the  heart  and  lungs,  or  of 
the  abdominal  organs.  Subcutaneous  ruptures  are  sometimes  followed  by  pro- 
lapse of  the  stomach  and  intestines;  sometimes  the  spleen  or  a  portion  of  the 
liver,  into  the  pleural  cavity.  If  much  of  the  contents  of  the  belly  lie  in 
the  thorax,  the  former  may  be  retracted  while  the  latter  is  distended.  Ac- 
cording to  circumstances,  marked  symptoms  may  or  may  not  be  present.  In 
some  cases  such  hernias  have  existed  for  years  unrecognized.  In  others  they 
have  caused  early  strangulation  of  the  gut  and  death.  In  cases  of  recent  pro- 
lapse there  may  be  symptoms  of  compression  of  the  heart  and  lungs,  dyspnea 
and  rapid  heart,  etc.  The  physical  signs  in  the  chest  may  be  characteristic. 
There  will  be  tympanitic  resonance  over  the  thorax  up  to  a  certain  level,  with 
absence  of  voice  and  breathing;  above,  there  may  be  normal  resonance  and 
feeble  or  normal  breathing.  There  may  be  splashing  sounds,  heard  spontane- 
ously or  on  shaking  the  patient.  If  the  stomach  is  in  the  pleural  cavity  and  an 
effervescent  drink  be  swallowed — a  Seidlitz  powder,  for  example — the  area  of 
tympanitic  resonance  may  be  increased  and  bubbling  sounds  may  be  heard. 
The  patient  may  suffer  from  colicky  pain,  from  dyspepsia ;  he  may  vomit.  If 
the  gut  becomes  constricted,  there  will  be  the  symptoms  of  intestinal  obstruc- 
tion. If  the  gut  ruptures  into  the  pleura,  a  putrid  pyopneumothorax  would 
speedily  develop.  Simultaneous  wounding  of  stomach  and  diaphragm  without 
prolapse  may  be  followed  by  the  escape  of  stomach  contents  into  the  pleura 
and  empyema.     Prolapse  of  lung  into  the  abdomen  is  rare. 

The  symptoms  referable  to  the  diaphragm  itself  in  cases  of  rupture  or  of 
wounds  may  be  slight  or  marked.  Pain  is  felt  in  the  region  of  the  diaphragm, 
made  worse  by  coughing,  vomiting,  or  taking  a  deep  breath ;  the  patient 
breathes  as  quietly  as  possible,  spares  his  diaphragm  all  he  can.  The  pain 
may  radiate  to  the  shoulder.  Severe  dyspnea  will  only  be  present  when  there 
are  associated  injuries  or  prolapse  of  the  viscera,  as  above.  Injury  of  the 
diaphragm  is  common  in  stab  and  gunshot  wounds  of  the  thorax  and  belly. 
The  existence  of  such  a  wound  may  be  inferred,  as,  for  example,  when  an 
individual,  shot  in  the  thorax,  has  symptoms  referable  to  the  belly — pain,  vom- 
iting, rigidity  of  the  abdominal  wall,  etc.  A  positive  diagnosis  can  rarely 
be  made  without  operative  exploration. 

Fractures  and  Dislocations 

Fracture  of  the  Sternum. — Except  as  the  result  of  gunshot  and  stab  wounds, 
this  is  a  rare  injury.  It  is  almost  unknown  in  childhood  and  very  rare  before 
adult  life.     The  line  of  fracture  is  most  often  transverse,  or  nearly  so,  rarely 


644  THE   THOEAX 

oblique,  and  very  rarely  longitudinal.  The  most  frequent  seat  of  fracture  is 
at  or  near  the  junction  of  the  manubrium  with  the  body  of  the  bone.  The 
manubrium  itself  may  be  broken  near  its  lower  border.  The  manubrium  may 
be  separated  from  the  body  by  a  fracture  or  a  dislocation,  according  to  whether 
ankylosis  has  taken  place  or  not,  or  the  fracture  may  be  through  the  body  near 
its  upper  border ;  less  frequent  is  a  fracture  of  the  middle  portion  of  the  body, 
and  very  rare  a  fracture  or  a  separation  of  the  ensiform  cartilage.  If  we 
except  gunshot  wounds  and  stabs,  fractures  of  the  sternum  are  nearly  always 
simple;  they  are  usually  complete,  but  in  many  cases  the  periosteum  of  the 
posterior  surface  is  wholly  or  partly  preserved.  They  may  be  produced  by 
external  violence  or  by  muscular  action.  External  violence  may  act  directly 
or  indirectly.  In  the  former  case  the  bone  is  broken  by  blows  or  falls  upon 
the  chest,  by  violent  compression,  as  in  run-over  accidents,  compression  between 
railway-car  buffers,  and  the  like.  In  the  latter  the  bone  may  be  broken  by 
extreme  bending  of  the  body  backward  or  forward.  Falls  upon  the  shoulders 
or  upon  the  dorsal  spine  produce  the  first.  The  bone  is  bent  backward  through 
its  muscular  and  ligamentous  attachments,  and  more  or  less  torn  apart.  Falls 
upon  the  buttocks  and  upon  the  breast,  such  that  the  body  is  forcibly  bent  for- 
ward, produce  the  second.  The  fractures  by  muscular  action  have  occurred  dur- 
ing straining  in  labor  and  by  efforts  to  lift  heavy  bodies,  notably  when  the  body 
was  bent  far  backward  and  the  individual  was  trying  to  lift  a  heavy  weight  by 
his  teeth.  The  common  form  of  displacement  in  fractures  of  the  manubrium 
and  of  the  body  is  forward  displacement  of  the  lower  fragment,  sometimes 
with  overriding.     The  upper  fragment  is  rarely  in  front  of  the  lower. 

The  diagnosis  is  usually  easy;  if  displacement  exists,  a  mistake  can  hardly 
occur.  The  patients  assume  by  preference  a  sitting  posture,  bend  the  body 
forward,  and  avoid  breathing  deeply.  There  is  localized  pain,  increased  by 
motion  or  by  deep  breathing,  often  mobility  of  the  fragments,  tenderness  at 
the  point  of  fracture,  crepitation  unless  the  fragments  override,  and  usually 
ecchymosis.  This  last  sign  is  of  especial  value,  if  it  appears  late,  in  cases 
where  no  deformity  is  present,  but  only  localized  pain  and  tenderness.  Asso- 
ciated injuries  may  give  rise  to  marked  symptoms :  rupture  of  the  lung  to 
pneumopericardium  and  subcutaneous  emphysema,  or  to  hemopneumothorax ; 
laceration  of  the  internal  mammary  artery  or  veins  to  hemopericardium  or  to 
abundant  extravasation  into  the  mediastinum,  with  pressure  symptoms  or  symp- 
toms of  hemorrhage.  Associated  injuries  of  the  heart  and  abdominal  viscera 
produce  severe  symptoms  which  overshadow  those  of  the  fracture.  Fractures 
and  dislocations  of  the  ensiform  cartilage  are  attended  by  the  signs  of  fracture. 
The  deformity  may  be  marked  ;  there  is  severe  pain,  tenderness,  and  mobility, 
and  in  several  recorded  cases  vomiting  of  a  persistent  character  only  relieved 
by  reduction  of  the  displacement.  The  congenital  deformities  of  the  sternum, 
notably  median  fissure,  should  be  borne  in  mind  when  examining  an  injury 
of  the  sternum,  as  well  as  the  varieties  in  the  shape  and  position  of  the  ensi- 
form cartilage. 


INJURIES    OF   THE    THORAX   AND   ITS   CONTENTS  64.5 

Dislocations  of  the  Sternum. — Dislocation  of  the  manubrium  from  the  body 
of  the  bone  has  been  occasionally  recorded.  Direct  and  indirect  violence  and 
muscular  action  have  been  given  as  causes.  In  a  large  proportion  of  the  cases 
the  associated  injuries  have  been  so  severe  as  to  destroy  life.  The  common 
form  of  displacement  has  been  of  the  body  upward  and  forward  on  the  manu- 
brium. In  a  small  number  the  body  was  displaced  backward ;  in  one  a  longi- 
tudinal separation  was  present  from  a  fall  from  a  height,  in  which  the  patient 
struck  upon  his  back  on  top  of  a  wall  in  such  a  manner  as  to  produce  hyper- 
extension  of  the  spine  (Aurran  and  David).  Forward  dislocations  of  the  body 
have  been  produced  by  blows  and  falls  upon  the  upper  part  of  the  chest;  falls 
from  a  height  such  that  the  spine  has  been  violently  flexed.  The  diagnosis 
depends  upon  the  recognition  of  the  deformity  and  displacement.  Inasmuch 
as  the  cartilages  of  the  second  ribs  usually  remain  attached  to  the  manubrium, 
in  the  anterior  dislocations  the  crescentic  hollows  at  either  upper  corner  of  the 
body  for  the  articulation  with  these  ribs  can  usually  be  recognized  on  palpa- 
tion, thus  differentiating  the  condition  from  fracture.  Generally  speaking, 
the  diagnosis  offers  no  difficulties.  The  associated  injuries  are  usually  more 
important.  In  those  cases  Avhich  have  survived,  inability  to  maintain  reduc- 
tion has  not  caused  any  serious  symptoms  (Stimson). 

Fractures  of  the  Ribs  and  of  their  Cartilages. — Fractures  of  the  ribs  and 
their  cartilages  are  very  common  injuries.  In  the  statistics  of  various  authors 
they  are  placed  second,  third,  or  fourth  in  point  of  frequency  among  fractures. 
They  are  exceedingly  rare  in  childhood ;  during  adult  life  they  increase  in 
frequency  among  men  during  the  active  working  period  and  diminish  during 
old  age.  Fractures  of  ribs  from  slight  degrees  of  violence  are  common  among 
insane  patients  and  paralytics.  The  ribs  may  be  broken  by  external  violence 
or  by  muscular  action,  the  latter  very  rarely.  Still,  numerous  cases  have  been 
observed  from  coughing,  sneezing,  straining.  The  accident  is  said  to  be  more 
common  on  the  left  side  and  of  the  lower  ribs,  especially  the  eleventh  (Stim- 
son). External  violence  is  the  ordinary  cause,  from  blows,  falls,  or  violent 
compression  of  the  chest.  Any  number  of  ribs  may  be  broken  on  one  or  both 
sides.  Compound  fractures  occur,  not  from  the  ribs  penetrating  the  skin  but 
from  the  wound  caused  by  the  object  producing  the  fracture.  The  ribs  most 
commonly  broken  are  the  sixth,  seventh,  and  eighth,  the  twelfth  rib  very  rarely. 
I  recently  saw  a  case,  verified  by  operation,  in  which  a  blow  in  the  loin  caused 
a  fracture  of  the  twelfth  rib  and  a  punctured  wound  of  the  kidney,  with 
hematuria  of  some  gravity,  for  which  I  exposed  the  kidney.  The  wound  of 
the  kidney  corresponded  in  size  to  the  rib,  and  was  about  an  inch  deep.  The 
upper  three  ribs  are  fractured  less  commonly  than  those  below.  The  fracture 
of  a  rib  may  be  complete  or  incomplete,  transverse  or  oblique.  Angular  de- 
formity may  occur,  notably  when  several  ribs  are  broken ;  the  angle  may  be 
directed  outwardly  or  inwardly.  Overriding  does  not  occur  except  when  several 
successive  ribs  are  broken.  Not  infrequently  a  rib  is  broken  in  two  places. 
Examples  of  four  points  of  fracture  in  one  rib  have  been  observed. 


646  THE   THOEAX 

Although  any  portion  of  a  rib  may  be  fractured,  the  most  common  situation 
is  in  front  near  the  junction  of  the  rib  with  its  cartilage,  less  commonly  in 
the  axillary  region,  rarely  near  its  junction  with  the  spine.  A  rib  may  be 
broken  by  direct  violence  at  the  point  of  impact,  or  a  force  which  compresses 
the  thorax  and  which  tends  to  crowd  the  ends  of  a  rib  nearer  together  may 
cause  a  fracture  at  the  point  of  greatest  convexity  of  the  curve.  In  practice  it 
is  not  always  easy  to  distinguish  between  these  two  forms.  Associated  injuries 
are  common — most  often  of  the  pleura  and  lung,  less  often  of  the  heart,  great 
vessels,  and  the  abdominal  viscera.  The  lung  may  be  wounded  by  the  broken 
fragments  of  rib,  or  burst  by  compression  at  another  point,  even  without  lacer- 
ation of  the  parietal  pleura.  Lacerations  of  the  lung  may  give  rise  to  hemo- 
thorax or  pneumothorax,  with  their  signs  and  symptoms.  Emphysema  of  the 
chest  wall — usually  limited  in  extent,  sometimes  generalized  over  the  entire 
body — is  one  of  the  commonest  and  most  certain  signs  of  fracture  of  ribs  and 
laceration  of  the  lung,  although  emphysema  is  more  likely  to  occur  where  the 
lung  is  adherent  to  the  chest  wall  at  the  point  of  fracture.  It  may  and  often 
does  occur  when  this  is  not  the  case. 

The  Diagnosis  of  Fractures  of  the  Ribs. — The  diagnosis  of  fractures  of  the 
ribs  is  not  usually  difficult,  but  no  doubt  many  fractured  ribs  are  unrecognized 
and  treated  as  contusions.  There  is  pain  at  the  seat  of  fracture,  increased  by 
deep  breathing;  there  is  often  a  painful  and  frequent  cough.  If  the  lung  is 
injured  there  may  be  bloody  expectoration,  often  present  in  slight  and  absent  in 
severe  injuries.  The  patients  try  to  hold  the  injured  side  of  the  thorax  as 
rigidly  as  possible,  and  to  avoid  coughing.  During  coughing  the  patient  may 
distinctly  feel  crepitation  at  the  point  of  fracture.  Associated  injuries  will 
produce  more  or  less  grave  symptoms  of  their  own.  (See  Subcutaneous  In- 
juries of  the  Thorax.)  Palpation  of  the  ribs  will  discover  a  point  of  extreme 
tenderness  at  the  site  of  fracture.  Pressure  upon  the  rib  at  a  distant  point 
will  often  cause  pain  at  the  same  place.  Pressure  upon  the  sternum  will  often 
produce  pain  at  the  point  of  fracture  in  the  rib.  In  many  cases  emphysema 
will  be  present.  In  cases  of  doubt,  each  rib,  where  accessible,  should  be  care- 
fully palpated.  Mobility  at  the  point  of  fracture  and  deformity  may  be  pres- 
ent ;  usually  they  are  absent  or  hard  to  recognize  unless  several  adjacent  ribs 
are  broken,  or,  in  the  case  of  a  single  rib,  unless  it  is  comminuted  or  broken 
in  more  than  one  place.  Crepitation  may  sometimes  be  felt  by  placing  the 
palm  of  the  hand  over  the  seat  of  fracture  while  the  patient  breathes,  or  by 
pressure  with  the  fingers  on  either  side  of  the  point  of  fracture  alternately. 
Auscultation  may  reveal  pleuritic  friction  sounds  under  the  fracture,  and 
crepitation  may  sometimes  be  heard  at  the  same  time. 

When  the  fracture  is  incomplete  a  positive  diagnosis  can  hardly  be  made, 
local  pain  and  tenderness  being  also  present  in  contusions.  Pneumo-  and 
hemothorax  give  their  proper  signs.  It  is  exceedingly  rare  that  an  uncom- 
plicated fracture  of  ribs  leads  to  empyema.  Pneumonia  may  occur  in  the 
aged,  the  feeble,  and  the  alcoholic.     A  rare  complication  of  fractured  ribs  is 


INJURIES    OF   THE    THORAX   AND   ITS    CONTENTS  647 

hernia  of  the  lung.  It  only  occurs  when  several  adjacent  ribs  are  broken,  and 
one  or  more  of  them  is  displaced  upward  or  downward  so  that  a  gap  occurs 
through  which  the  lung  protrudes.  It  is  rarely  that  the  X-rays  are  needed 
to  confirm  a  diagnosis  of  fractured 'ribs.  In  the  extensive  fractures  of  many 
ribs  near  the  spine,  occasionally  observed,  the  gravity  of  the  injury  depends 
upon  lesions  more  important  than  the  fractures  of  the  ribs  themselves;  but 
in  these  cases  the  X-rays  might  afford  information  in  regard  to  the  ribs  not 
otherwise  obtainable.  The  presence  of  fractures,  with  displacement  old  or  new, 
could  readily  be  shown.  The  suspected  part  of  the  thorax  should  be  placed 
as  close  as  possible  to  the  photographic  plate. 

Fracture  of  the  Costal  Cartilages. — Fracture  of  the  costal  cartilages  is  not 
a  very  common  injury ;  it  may  be  produced  by  the  same  causes  as  fractures 
of  ribs.  The  fracture  occurs  more  often  in  elderly  men  whose  costal  cartilages 
have  undergone  partial  ossification.  I  have  recently  seen  a  case  in  a  young 
man  due  to  a  fall  against  the  corner  of  a  bureau.  The  cartilage  of  the 
seventh  rib  was  broken  close  to  its  junction  with  the  rib;  there  was  easily 
recognized  deformity.  The  end  of  the  rib  projected  anteriorly ;  the  cartilage 
was  slightly  depressed,  this  being  the  usual  condition.  The  sixth,  seventh, 
and  eighth  ribs  are  broken  in  this  way  oftener  than  others.  If  overriding 
is  not  present,  mobility  and  soft  crepitation  may  be  felt.  Under  certain 
conditions  many  cartilages  may  be  fractured,  with  serious  or  fatal  injuries 
of  the  thoracic  viscera,  as  in  cases  of  compression  of  the  thorax  already 
described. 

Dislocations  of  the  Ribs. — Dislocations  of  ribs  at  the  costovertebral  articula- 
tions have  been  observed  in  a  few  cases,  for  the  most  part  at  autopsies,  death 
having  occurred  from  associated  injuries.  In  a  number  of  instances  fractures 
of  the  vertebra?  and  of  other  ribs  existed.  These  dislocations  are  very  unlikely 
to  occur  as  isolated  injuries,  but  one  case  of  this  kind  having  been  recorded 
(Stimson).  It  is  improbable  that  a  diagnosis  could  be  made  by  any  other 
means  save  the  X-rays,  or  during  an  operation  for  fractured  spine.  There  is 
no  reason  to  suppose  that  subjective  symptoms  are  produced  which  would  mate- 
rially differ  from  those  of  fractured  ribs. 

Dislocations  of  Ribs  from  (heir  Cartilages. — Dislocations  of  ribs  from  their 
cartilages  are  infrequent.  They  may  be  produced  by  direct  and  indirect  vio- 
lence, and  by  muscular  action.  The  signs  and  symptoms  closely  resemble 
those  of  fracture  of  the  costal  cartilages.  In  anterior  dislocation  the  pro- 
jecting extremity  of  the  rib  is  unmistakable.  In  some  cases  the  deformity, 
easily  reduced,  has  returned  at  once.  There  may  or  may  not  be  local  pain ; 
tenderness  is  present.  The  condition  may  sometimes  be  distinguished  from 
fracture  of  the  cartilage  by  its  situation  and  the  shape  and  contour  of  the 
end  of  the  rib.  Dislocation  of  the  costal  cartilages  from  the  sternum  has 
been  observed  in  a  few  cases,  sometimes  associated  with  fractures  of  ribs, 
dislocation  of  the  clavicle  at  its  inner  end,  and  fracture  of  the  sternum. 
After  the  history  of  a  suitable  injury  the  signs  and  symptoms  are  localized 


648  THE   THORAX 

pain  and  tenderness  following  the  accident,  together  with  deformity  felt  on 
palpation.     The  usual  displacement  has  been  backward. 

Separation  of  the  Cartilages  of  the  Ribs  from  One  Another. — Separation 
of  the  cartilages  of  the  sixth,  seventh,  and  eighth  ribs  from  one  another  has 
been  observed  and  recorded  in  a  few  cases  only,  caused  by  a  fall  or  violent 
bending  of  the  body  backward.  The  cartilages  have  been  found  separated — in 
one  case  (Hochenegg)  widely — and  movable  upon  one  another. 

DISEASES   OF  THE  THORACIC   WALL 

The  skin  of  the  upper  part  of  the  back  is  one  of  the  commonest  sites  of  the 
various  forms  of  acne ;  the  eruption  is  chronic  here  as-  elsewhere,  and  appears 
to  depend  partly  upon  constitutional  causes  and  partly  upon  want  of  due  care 
of  the  skin.  The  acne  papules  and  pustules  are  scarcely  to  be  confounded 
with  other  skin  diseases.  They  lack  the  peculiar  pigmentation  and  coloring 
of  syphilides,  and  do  not  form  the  circular  and  crescentic  groupings  of  syphil- 
itic papules  and  pustules.  The  back  of  the  neck  and  shoulders  are  also  favor- 
ite sites  for  furuncles  and  carbuncles.      (See  General  Surgery.) 

Acute  Phlegmonous  Inflammation  of  the  Soft  Parts  of  the  Thorax. — A  dan- 
gerous and  often  fatal  necrotic  and  purulent  inflammation  of  the  connective- 
tissue  planes  of  the  chest,  involving  especially  the  intermuscular  planes,  some- 
times the  muscles  and  the  subcutaneous  fat,  may  originate  in  a  variety  of  ways. 
It  may  follow  infection  through  the  nipple  or  abscess  of  the  breast ;  infected 
wounds  or  operations  on  the  soft  parts  of  the  thorax;  periglandular  infection 
from  suppurating  axillary  lymph  glands ;  suppurative  processes  originating  in 
the  jaw  or  in  the  neck,  notably  in  the  supraclavicular  fossa,  which  burrow 
down  into  the  axilla.  Beneath  the  scapula  and  beneath  the  pectoralis  major 
muscle  are  not  uncommon  sites.  The  symptoms  are  those  of  acute  sepsis ;  a 
chill  may  occur,  with  high  fever,  prostration,  a  high  leucocyte  count,  etc. 
Locally,  there  is  general  pain  and  tenderness  over  the  affected  side.  The  loose 
intermuscular  planes  favor  the  spread  of  infection  over  a  large  area  rather 
than  localization  and  perforation  of  the  skin.  After  the  process  is  well  under 
way  a  diffuse  boggy  swelling  may  be  present,  or  a  boardlike  induration.  The 
disease  has  been  mistaken  for  pleurisy ;  the  constitutional  symptoms  are  far 
more  stormy  and  the  signs  of  pleurisy  are  absent.  The  use  of  an  aspirating 
needle  and  the  withdrawal  of  pus,  together  with  the  general  symptoms  of  pro- 
found sepsis,  will  establish  the  diagnosis. 

Abscesses  of  the  Thoracic  Wall. — Acute  abscesses  arise  from  infection 
through  a  wound  or  abrasion  of  the  skin ;  from  the  presence  of  a  foreign  body ; 
infection  of  a  hematoma;  further,  from  osteomyelitis  of  a  rib  or  the  sternum. 
The  signs  of  acute  abscess  are  present ;  an  aspirating  needle  withdraws  pus. 
The  causation  is  to  be  determined  partly  from  the  history,  partly  from  the 
findings  when  the  abscess  is  incised.  An  empyema  which  has  perforated  the 
chest  wall — so-called  "  empyema  necessitatis  " — is  to  be  differentiated  from  an 


DISEASES    OF   THE    THORACIC    WALL  649 

ordinary  abscess  by  percussion  and  auscultation  of  the  chest,  by  the  introduc- 
tion of  an  aspirating  needle  into  the  pleural  sac,  and  the  presence  of  dyspnea, 
cough,  and  immobility  of  the  chest. 

Peripleuritic  Abscess. — Primary  acute  abscess  originating  outside  the 
costal  pleura  and  beneath  the  ribs  is  a  rare  condition.  The  abscess  may  be  of 
considerable  size,  and  tends  to  perforate  the  chest  wall  rather  than  the  pleura, 
and  appears  as  a  tender,  fluctuating  swelling,  giving  the  local  signs  of  deep- 
seated  acute  or  subacute  abscess.  The  differential  diagnosis  from  a  perforating 
empyema  may  be  impossible.  The  following  consideration  may  be  of  value: 
A  peripleuritic  abscess  may  appear  anywhere  and  be  surrounded  by  normal 
resonance  and  breathing;  an  empyema  is  usually  at  the  bottom  of  the 
pleural  sac;  abscess  of  the  lung  may  perforate  the  chest  wall  and  form  a 
tumor  giving  the  signs  of  abscess  beneath  the  skin.  There  will  usually  have 
been  a  history  of  pneumonia,  an  injury,  aspiration  of  a  foreign  body,  etc. 
Failing  some  such  history,  the  condition  may  remain  unrecognized  until  incised 
and  explored.  Tuberculous  cavities  in  the  lungs  may  occasionally  perforate 
the  thoracic  wall  and  give  rise  to  an  abscess  containing  pus  and  air.  Such,  an 
abscess  will  give  a  tympanitic  percussion  note  and  will  not  usually  be  reducible ; 
aspiration  will  withdraw  pus  and  air.  A  hernia  of  the  lung,  unless  strangu- 
lated or  inflamed,  will  be  reducible,  and  vesicular  breathing  may  be  heard  over 
it  as  well  as  tympanitic  resonance.  There  are  a  number  of  instances  on  record 
where  an  aneurism  of  the  aorta  has  perforated  the  chest  wall  and  been  incised 
as  an  abscess.  The  skin  over  such  an  aneurism  may  be  acutely  inflamed,  fluc- 
tuation is  present ;  if  the  sac  is  much  thickened,  or  partly  obliterated  by  layers 
of  fibrin,  pulsation  and  bruit  may  be  wanting.  In  any  doubtful  case  a  fine 
needle  should  be  introduced,  and  the  character  of  the  contained  fluid  deter- 
mined. It  is  to  be  remembered  that  if  the  sac  contains  clots,  a  dry  tap  may 
result.  Further,  an  abscess  may  overlie  an  aneurism.  Under  such  condi- 
tions a  careful  physical  examination,  the  history  of  the  case,  and  ordinary  care 
will  prevent  disastrous  error.  An  X-ray  examination  is  a  useful  aid  in  the 
diagnosis. 

Actinomycosis. — Actinomycosis  of  the  lung  may  perforate  and  produce  an 
actinomycotic  abscess  of  the  chest  wall.  The  disease  is  characterized  by  a  very 
chronic  course,  by  the  formation  of  abscesses  and  .sinuses  with  indurated  walls, 
and  by  the  presence  of  the  characteristic  granules  in  the  discharge.  (See 
Actinomycosis.) 

Cold  Abscess  or  the  Thoracic  Wall. — Tuberculous  abscess  gives  the 
history  of  a  chronic  process  without  signs  of  acute  inflammation;  the  fluctuat- 
ing swelling  is  covered  by  white  skin,  is  painless  and  insensitive.  The  size 
of  such  an  abscess  may  be  small  or  very  large,  in  some  cases  as  large'  as  a 
child's  head.  In  most  cases  a  cold  abscess  will  have  originated  in  a  bone,  a 
rib,  the  sternum,  a  vertebra,  the  scapula,  and  often,  at  some  distance  away, 
the  pus  having  traveled  perhaps  a  foot  or  more,  beneath  the  muscles,  before  it 
has   reached  the   surface.      Primary  tuberculosis   of  muscles  being  rare,   the 


650  THE   THORAX 

possibility  of  an  intrathoracic  origin  should  not  be  forgotten,  and  careful 
search  with  a  fine  probe  may  reveal  it  during  the  operation. 

Acute  Osteomyelitis  of  the  Ribs,  Sternum,  or  Clavicle. — Acute  osteomyelitis 
of  the  ribs,  sternum,  or  clavicle  rarely  occurs  as  an  isolated  lesion;  usually 
other  bones,  and  notably  the  long  bones  of  the  extremities,  are  simultaneously 
involved.  A  few  such  cases  have,  however,  been  recorded,  especially  after 
typhoid  fever  and  other  infectious  diseases.  Local  pain,  tenderness,  and  swell- 
ing, and  the  formation  of  an  abscess,  together  with  the  suppurative  lesion  in 
the  bone  and  periosteum,  are  present.  In  the  case  of  the  ribs  the  anterior 
extremities  appear  to  be  most  commonly  affected.  I  saw  a  focus  in  the 
manubrium  and  the  sixth  rib  associated  with  acute  osteomyelitis  of  the 
tibia ;  a  similar  lesion  was  observed  in  another  case  after  a  cellulitis  of 
the  forearm. 

Tuberculous  Periostitis  and  Osteomyelitis  of  Ribs  and  Sternum. — Tuberculous 
periostitis  and  osteomyelitis  of  ribs  and  sternum  is  more  common  than  the 
acute  suppurative  form;  the  ribs  are  more  often  affected  than  the  sternum. 
The  disease  occurs  at  all  ages;  in  children  and  old  people  less  often  than  in 
young  and  middle-aged  adults.  The  lesion  may  be  primary  in  the  periosteum 
and  bone,  or  secondary  to  tuberculosis  of  the  soft  parts  or  to  intrathoracic 
lesions.  Other  tuberculous  lesions,  notably  phthisis,  are  often  present.  Pri- 
mary tuberculosis  in  the  bone  is  the  rule,  in  the  periosteum  the  exception. 
The  lesions  are  tuberculous  infiltration  of  an  area  of  bone,  usually  limited  in 
extent,  softening,  the  formation  of  an  abscess,  sometimes  of  a  small  sequestrum. 
The  tendency  to  burrow  beneath  or  through  the  pleura  is  small,  the  abscess 
finds  its  way  outwardly.  Primary  tuberculous  periostitis,  by  depriving  the 
rib  of  its  blood  supply,  may  lead  to  the  formation  of  a  considerable  sequestrum. 
Several  foci  may  exist  in  one  bone  or  many  ribs  may  be  involved.  The 
perichondrium  of  the  costal  cartilages  may  also  be  the  seat  of  tuberculosis. 
The  cartilage  undergoes  necrosis,  and  remains  as  a  sequestrum  at  the  bottom 
of  a  chronic  tuberculous  sinus.  In  the  sternum  multiple  foci  often  form,  so 
that  a  considerable  portion,  or  even  the  entire  sternum,  may  be  involved.  The 
abscesses  usually  break  through  the  skin,  leaving  tuberculous  sinuses  and 
ulcers  behind.  Rarely,  such  abscesses  form  on  the  posterior  surface  and  break 
into  the  mediastinum,  to  end  fatally.  The  diagnosis  of  tuberculosis  of  ribs 
and  sternum  is  not  often  difficult;  there  is  a  history  of  a  chronic,  painless, 
circumscribed  enlargement  of  one  or  more  ribs,  or  of  a  similar  tumor  over 
the  sternum;  the  formation  of  a  cold  abscess,  which  finally  perforates  the 
skin  and  discharges  abundant  tuberculous  pus.  The  probe  often  strikes  imme- 
diately against  bare,  roughened,  or  softened  carious  bone.  Should  the  fistu- 
lous tract  be  long  or  tortuous,  and  difficult  to  follow  with  a  probe,  the  follow- 
ing expedient  may  be  used  to  find  the  original  focus:  The  sinus  is  injected 
with  iodoform  or  bismuth  emulsion;  an  X-ray  picture  is  taken;  the  iodoform 
or  bismuth  casts  a  dense  shadow,  and  often  indicates  plainly  the  point  of  origin 
of  the  process. 


DISEASES    OF   THE   THORACIC   WALL  651 

Syphilitic  Periostitis  and  Osteomyelitis  of  Ribs  and  Sternum. — Syphilitic 
periostitis  and  osteomyelitis  of  ribs  and  sternum  occurs  in  the  later  stages  of 
the  disease  as  a  circumscribed,  or  more  diffuse,  gummatous  infiltration  of  the 
periosteum  or  bone,  or  both.  There  is  formed  a  slowly  growing  circumscribed 
enlargement  of  the  rib,  often  spindle-shaped,  tending  to  spread  along  the  length 
of  the  rib,  and  generally  nearly  painless.  Upon  the  sternum  a  more  or  less 
prominent  tumor  is  formed,  hard  or  elastic  at  first ;  later,  softening  may  take 
place,  with  the  formation  of  a  characteristic  crateriform  gummatous  ulcer 
leading  to  exposed  or  necrotic  bone,  or  to  one  or  more  sinuses,  not  always  easy 
to  distinguish  from  tuberculosis.  Points  which  may  aid  in  diagnosis  are: 
Syphilitic  gummy  material  of  a  dirty-white  homogeneous  appearance  may  be 
visible ;  syphilitic  pus  is  often  thick,  and  does  not  contain  flocculi  of  cheesy 
material,  as  does  tuberculous  pus.  Other  signs,  or  a  history  of  syphilis  may 
be  obtained.  Syphilis  responds  to  iodid  and  mercury.  It  is  to  be  borne  in 
mind  that  syphilis  and  tubercle  may  coexist  in  the  same  lesion.  Before  break- 
ing down,  gummata  are  often  mistaken  for  sarcomata ;  the  diagnosis  is  not 
always  possible  without  vigorous  antisyphilitic  treatment. 

Intercostal  Neuralgias. — Under  this  title  I  intend  to  mention  painful  affec- 
tions of  the  intercostal  nerves  from  various  causes,  whether  true  neuralgias  or 
not,  among  them  the  expression  of  an  anemic,  hysterical,  or  neurasthenic  state. 
Neuritis,  sometimes  associated  with  herpes  zoster  of  the  chest  wall.  Exposure 
to  cold  and  wet ;  autointoxication  from  the  intestinal  tract,  gout,  uric-acid,  and 
rheumatism  are  regarded  as  adequate  causes  by  some  observers.  Deformities 
and  diseases  of  the  spine ;  fractures  of  ribs,  with  deformity  or  pressure  upon 
the  nerves  by  callus  formation.  Pressure  by  inflammatory  infiltrations  or  new 
growths.  All  these  conditions,  and  even  others,  must  be  taken  into  account  in 
arriving  at  a  diagnosis.  The  pain  will  vary  in  character  in  different  cases. 
In  true  neuralgias  without  evident  organic  lesion  it  is  apt  to  be  paroxysmal 
and  severe,  with  intermissions.  The  pain  following  exposure  to  cold  and  wet 
is  felt  chiefly  during  active  movements  of  the  intercostal  muscles.  Pain  due 
to  the  pressure  of  tumors,  callus  formation,  and  aneurism  is  apt  to  be  contin- 
uous with  exacerbations.  The  conditions  are  here  mentioned  because  the  true 
neuralgias,  if  persistent,  are  sometimes  treated  surgically  by  stretching  or 
avulsion  of  the  nerves. 

Tumors  of  the  Thoracic  Wall. — All  the  varieties  of  benign  and  malignant 
tumors  may  occur  in  the  soft  tissues  and  bony  framework  of  the  thorax. 
Lipoma  is  the  most  frequent;  for  its  general  characters,  see  Tumors.  On  the 
thorax  they  form  sessile  or  pedunculated  growths  which  may  reach  an  enor- 
mous size,  and  interfere,  by  their  weight,  with  locomotion.  A  submammary 
lipoma  may  have  the  appearance  of  an  hypertrophied  breast;  the  gland  may 
undergo  atrophy  from  pressure.  A  few  cases  of  lipoma  have  been  observed 
in  which  the  tumor  lay  partly  within,  partly  without,  the  thoracic  cavity  (sub- 
pleural  lipoma).  The  two  portions  of  the  growth  have  communicated  by  a 
narrow  isthmus.     Fibromata  in  the  form  of  fibroma  molluscum  and  keloid  are 


652 


THE   THOEAX 


very  common.  (See  Tumors.)  Other  fibromata  occur  deeply  seated  beneath 
the  muscles.  They  are  to  be  distinguished  from  lipoma  by  their  dense,  hard 
consistence,  and  by  the  fact  that  the  deep  lipomata  are  very  movable  tumors, 

while  the  fibromata  are  notably  less 
so.  These  deep  fibromata  may  also 
have  a  partially  subpleural  situa- 
tion. Hemangiomata  of  various 
types  also  occur,  and  present  their 
ordinary  characters.  I  saw,  some 
years  ago,  an  enormous  congenital 
cavernous  angioma  of  the  thorax. 
The  patient  was  a  man  of  thirty 
years.  The  tumor  occupied  the  en- 
tire axilla,  and  extended  well  for- 
ward to  the  mammary  line,  and 
downward  in  the  mid-axilla,  nearly 
to  the  costal  border;  it  formed  a 
blue,  spongy  mass,  easily  compres- 
sible, containing  large  venous  chan- 
nels and  spaces.  No  operation  was 
possible,  and  its  possessor  very  prop- 
erly guarded  it  from  injury  with 
jealous  care.  The  cavernous  angi- 
omata  sometimes  remain  stationary 
for  years  and  suddenly  take  on  a 
rapid  growth.  Hence  the  wisdom 
of  early  removal.  Hairy  and  pig- 
mented nevi  are  quite  common  upon 
the  chest  and  back,  and  if  they 
become  large  may,  in  women,  be- 
come worthy  of  operative  removal. 
They  are  sometimes  the  starting 
point  of  melano-sarcoma.  Neuroma  and  neurofibroma  of  the  cutaneous  and 
intercostal  nerves  of  the  thorax  are  not  rare ;  they  present  as  nodules,  sometimes 
tender  and  painful,  in  the  course  of  the  nerves.  (See  Neuroma.)  Plexiform 
neuroma  of  the  intercostal  nerves  has  been  observed.  I  removed  a  plexiform 
neuroma  from  the  dorsal  region  just  to  one  side  of  the  spine.  The  patient  was 
a  young  girl.  The  tumor  formed  a  soft,  slightly  elevated  mass  beneath  the  skin, 
circular  in  shape,  and  as  large  as  a  tea  saucer.  There  had  been  no  pain  in  the 
growth.  The  bundles  and  fusiform  masses  of  soft  gelatinous  tissue  extended 
deeply  into  the  muscles  of  the  back,  and  required  quite  a  bloody  dissection  for 
their  removal.     The  reported  cases  are  not  numerous. 

Lyrnphangiomata  have  their  origin  in  or  near  the  axilla  in  the  majority  of 
cases;  they  form  soft  tumors,  usually  mistaken  for  lipomata.     An  aspirating 


Fig.  237. — Lipoma  of  the  Thoracic  Wall. 
(New  York  Hospital,  service  of  Dr.  Bolton.) 


DISEASES    OF   THE    THORACIC    WALL  653 

needle  introduced  in  the  tumor  withdraws  clear,  colorless,  or  straw-colored 
fluid.  Like  the  cavernous  hemangiomata,  they  sometimes  begin  to  grow  rap- 
idly, and  may  penetrate  deeply  beneath  the  muscles  and  into  the  cavity  of 
the  thorax.  Atheromatous  and  dermoid  cysts  may  occur,  notably  in  the  back. 
(See  Tumors.) 

Enchondeomata  of  the  Ribs  and  Sternum. — Cartilaginous  tumors 
grow,  commonly,  from  the  junction  of  a  rib  with  its  cartilage.  Less  often  from 
the  sternum,  and,  in  all  the  recorded  cases,  from  the  body  of  the  bone.  They 
may  follow  contusions  or  fractures  of  ribs.  They  form  slow-growing  painless 
nodules  of  smooth  or  irregular  contour  attached  to  a  rib.  After  they  have 
attained  a  certain  size,  they  usually  undergo  a  central  or  disseminated  myx- 
omatous degeneration,  so  that  there  may  be  a  thin  cartilaginous  shell  inclos- 
ing a  cavity  filled  with  mucous  tissue ;  or  the  tumor  may  consist  of  irregularly 
distributed,  hard  and  soft  areas.  Combinations  with  sarcoma  and  sarcomatous 
degenerations  of  cartilaginous  tumors  are  frequent.  The  enchondromata  of 
the  ribs  quite  commonly  recur  after  operation  and  form  metastases ;  they  are, 
thus,  dangerous  tumors.  Since  they  grow  slowly,  and  are  not  painful,  they 
are  first  seen  by  surgeons  after  they  have  reached  a  considerable  size.  They 
may  have  included  several  ribs  and  grown  inward,  involving  the  pleura  and 
mediastinum.  If  let  alone,  pressure  symptoms  of  progressively  dangerous  char- 
acter occur,  and  finally  destroy  life.  Their  early  operative  removal  is,  there- 
fore, highly  important. 

Sarcoma  of  the  Thoracic  Wale. — Primary  sarcoma  of  the  thorax  takes 
origin  commonly  in  the  ribs  and  sternum,  either  from  periosteum  or  bone  sub- 
stance. They  are  generally  very  malignant  and  dangerous  tumors,  of  rapid 
growth  and  of  various  degrees  of  hardness,  according  to  the  character  of  tissue 
composing  them.  Localized  or  generalized  softening  is  common  from  degen- 
erative changes.  They  usually  invade  the  pleura  quite  early,  and  involve  a 
wider  area  of  tissue  than  external  appearances  would  indicate.  Externally 
they  sometimes  break  down,  form  fungating  tumor  masses,  which  may  bleed 
the  patient  to  death  (see  Fig.  77).  Secondary  tumors  are  formed  in  the 
vicinity  of  the  primary  growth  and  metastases  in  distant  organs.  As  stated, 
they  often  occur  in  combination  with  chondroma.  Central  sarcoma  of  a  rib 
is,  at  least  in  the  beginning,  rather  less  malignant  than  the  periosteal  type. 
The  periosteum  may  remain  intact  for  some  time.  A  fusiform  swelling  of  the 
rib  occurs  of  fairly  rapid  growth.  Early  operation  may  save  life.  Certain 
highly  vascular  sarcomata,  originating  in  the  sternum,  may  form  soft  pulsat- 
ing tumors,  somewhat  resembling  an  aneurism  of  the  aorta  after  it  has  per- 
forated the  sternum ;  the  pulsation  may  also  be  a  transmitted  one,  if  the  tumor 
has  destroyed  the  sternum  and  invaded  the  mediastinum.  Primary  sarcomata 
of  the  skin  and  soft  parts  of  the  thorax  are  rather  rare  tumors.  They  usually 
occur  as  multiple  nodular  tumors  in  the  skin,  which  grow  rapidly,  ulcerate, 
and  destroy  life  in  one  or  other  manner  common  to  malignant  tumors.  I 
removed  a  large  rapidly  growing  sarcoma  from  the  axilla  of  a  woman  some 


654 


THE    THORAX 


years  ago.     The  healthy  tissues  were  widely  excised.     The  woman  had  remained 
well  for  several  years  when  I  lost  sight  of  her. 

Carcdstoma  of  the  Thoracic  Wall. — Primary  carcinoma  of  the  skin 
occurs  chiefly  as  slow-growing  superficial  epithelioma,  with  ulceration,  but  no 
notable  tendency  to  invade  the  deeper  tissues  or  to  form  metastases.      (See 

Tumors.)  Secondary  carci- 
noma occurs,  for  the  most 
part,  secondary  to  carcino- 
ma of  the  breast.  (1)  As 
multiple  nodular  tumors 
scattered  over  the  skin  of 
the  .chest,  sometimes  of  the 
abdomen  and  back ;  the  nod- 
ules are,  at  first,  quite  small 
— as  large  as  a  pea — of 
stony  hardness,  in  the  thick- 
ness of  the  skin  (carcinoma 
lenticulare).  They  continue 
to  grow  and  coalesce.  I 
have  seen  them  come  out 
in  successive  crops  at  inter- 
vals of  a  few  months.  (2) 
As  a  diffuse  boardlike  infil- 
tration of  the  skin  and  un- 
derlying soft  parts,  firmly 
adherent  to  the  ribs,  consti- 
tuting the  condition  known  as  "  cancer  en  cuirasse."  The  prognosis  of  these 
cases  is  absolutely  bad  under  any  form  of  treatment,  including  the  X-rays. 

Echinococcus  has  been  observed  a  few  times  in  the  thoracic  wall,  usually 
in  the  muscles.  The  tumor  gives  the  physical  signs  of  a  cyst,  or  has  been  mis- 
taken for  lipoma.  The  diagnosis  rests  upon  the  aspiration  of  clear  fluid  and 
the  finding  of  booklets.  If  inflamed, 
(See  Echinococcus.) 


Fig.  238. —  Cancer  en  Cuirasse  Following  Carcinoma  of 
the  Breast.  Note  the  enormous  edema  of  the  right  arm 
from  pressure  upon  the  axillary  vein.  (Kindness  of  Dr.  B. 
S.  Barringer.) 


the  diagnosis  of  abscess  would  be  made. 


DISEASES   OF   THE   PLEURA 


General  Considerations. — From  the  surgical  standpoint,  the  injuries  and  dis- 
eases of  the  pleura  attended  by  an  accumulation  of  fluid  in  the  pleural  sac  are 
of  diagnostic  interest.  Such  accumulations  are  of  a  very  varied  character,  and 
give  rise  to  symptoms  of  two  kinds:  those  due  to  pressure  upon  the  intra- 
thoracic organs,  and  those  due  to  the  special  causative  factor  of  the  process 
and  to  the  character  of  the  fluid  itself.  The  pressure  symptoms  occur  only 
when  the  fluid  is  large  in  amount,  so  that  the  lung  upon  the  affected  side  is 
compressed  and  ceases  to  functionate  more  or  less  completely.  The  heart  is 
displaced;  the  function  of  the  other  lung  is  more  or  less  interfered  with;  the 


DISEASES    OF   THE   PLEURA  655 

blood-vessels  and  other  structures  in  the  mediastinum  may  be  seriously  com- 
pressed. The  symptoms  are  dyspnea,  cyanosis,  and. a  rapid  pulse-rate.  On  inspec- 
tion and  measurement,  the  affected  side  of  the  chest  is  distended  and  immobile. 
The  intercostal  grooves  are  obliterated ;  in  children  they  may  even  bulge.  In 
measuring  the  chest  with  the  cyrtometer,  it  is  to  be  remembered  that,  normally, 
the  right  side  of  the  chest  measures  about  half  an  inch  more  than  the  left  in 
right-handed  people.  The  measurements  may  be  made  at  the  level  of  the 
nipple  or  the  angle  of  the  scapula  with  the  arms  abducted  to  a  right  angle 
with  the  body.  A  convenient  tape  consists  of  a  fairly  thick  strip  of  lead  applied 
to  the  skin.  This  retains  its  shape,  so  that  a  tracing  of  the  shape  of  the  two 
sides  of  the  chest  may  be  made  on  a  sheet  of  paper,  measured  and  compared. 
In  large  pleuritic  effusions  the  difference  may  amount  to  an  inch  or  an  inch 
and  a  half. 

Palpation. — There  is  absence  or  diminution  of  vocal  fremitus,  sometimes 
preserved  in  children,  and  rarely  transmitted  through  adhesions  of  lung  to 
the  chest  Avail.  Percussion  gives  a  flat  note  over  the  fluid ;  by  this  means  an 
increase  in  the  quantity  of  fluid  may  be  measured  from  time  to  time.  If  the 
effusion  is  large,  there  is  tympanitic  resonance  of  a  peculiarly  resistant  board- 
like quality  above  the  level  of  the  fluid  over  the  compressed  lung.  This  is  to 
be  noted  especially  in  the  infraclavicular  and  supraclavicular  regions,  and 
in  the  supraspinous  fossa.  The  level  of  the  fluid  is  higher  behind  than  in 
front  when  the  patient  is  in  the  erect  position.  Sometimes  the  level  of  the 
fluid  and  the  signs  may  be  made  to  change  by  shifting  the  position  of  the 
patient. 

Auscultation. — Before  an  effusion  is  marked,  there  is  sometimes  a  creaking 
friction  sound  or  fine  crepitation  where  the  inflamed  pleural  surfaces  are 
rubbing  one  on  the  other.  When  the  fluid  has  accumulated  in  quantity  there 
is  absence  of  breathing,  or  diminished  breathing.  The  breathing,  though  dis- 
tant, may  be  high-pitched  and  bronchial.  Over  the  compressed  lung  there  is 
roughened  breathing,  often  high-pitched ;  rales  of  various  kinds  may  be  present. 
Over  the  fluid  there  is  absence  of  voice  or  distant  voice.  Bronchial  voice  some- 
times over  the  fluid,  but  especially  at  the  level  of  the  fluid  there  is  egophony 
- — i.  e.,  the  voice  has  a  nasal,  bleating  quality.  If  the  pleural  cavity  is  oblit- 
erated by  adhesions  no  effusion  can  occur.  If  localized  adhesions  exist,  fluid 
may  accumulate  over  limited  areas ;  the  physical  signs  will  then  vary,  according 
to  local  conditions.  The  apex  beat  of  the  heart  is  displaced  to  one  or  the  other 
side.  "  In  right-sided  effusions  the  apex  beat  may  be  lifted  to  the  fourth 
interspace  or  be  pushed  beyond  the  left  nipple,  or  may  even  be  seen  in  the 
axilla.  When  the  exudation  is  on  the  left  side  the  heart's  impulse  may  not  be 
visible ;  but  if  the  effusion  is  large,  it  is  seen  in  the  third  and  fourth  spaces 
on  the  right  side,  and  sometimes  as  far  out  as  the  nipple,  or  even  beyond  it  " 
(Osier).  (For  further  details  the  reader  is  referred  to  works  on  internal 
medicine.)  In  discussing  the  causation  of  special  kinds  of  pleuritic  effusions 
and  their  diagnosis,  it  is  convenient  to  divide  them  into  several  groups:  I. 


656  THE   THOEAX 

Inflammatory  effusions — serous,  sero-nbrinous,  and  purulent.  II.  Transuda- 
tions due  to  circulatory  disturbances.     III.  Hemothorax.     IV.   Chylothorax. 

Inflammatory  Effusions, —  With  the  exception  of  infection  accompanying 
open  wounds  of  the  pleural  sac,  inflammations  of  the  pleura  are  usually  sec- 
ondary to  general  infections  or  to  local  processes  of  varied  character.  .Any  of 
the  inflammations  of  the  lung;  pneumonias  of  all  kinds;  abscess  and  gangrene 
of  the  lung  may  be,  and  often  are,  accompanied  by  pleuritis;  abscess  or  cellu- 
litis of  the  mediastinum;  malignant  tumors  of  the  mediastinum  and  lung; 
infected  bronchial  glands;  ulcerated  carcinoma  of  the  gullet;  inflammatory 
processes  of  the  peritoneum,  or  of  any  of  the  abdominal  viscera,  with  or  with- 
out an  abscess  which  perforates  the  diaphragm.  The  character  of  the  fluid 
exudate  may  be  serous,  sero-sanguinolent,  sero-purulent,  purulent,  or  putrid. 
The  recognition  in  the  exudate  of  bacteria  is  often  very  important  in  the  diag- 
nosis, treatment,  and  prognosis  of  the  case.  While  very  many  bacterial  forms 
have  been  found,  the  pneumococcus,  the  pyogenic  staphylococci  and  strepto- 
cocci, the  tubercle  bacillus,  and  various  saprophytic  forms,  are  those  which  give 
a  more  or  less  distinctive  character  to  the  disease.  It  often  happens  that  sev- 
eral forms  are  associated.  A  purely  serous  pleuritis — the  fluid  being  clear,  or 
nearly  so,  containing  few  cellular  elements,  and  sterile — seldom  requires  surgi- 
cal treatment.  Many  of  the  cases  are  doubtless  tubercular.  It  is  believed  that 
the  poison  of  acute  articular  rheumatism,  or  even  exposure  to  cold  and  wet, 
may  act  as  an  exciting  cause.  The  fever  and  constitutional  disturbance  are 
moderate.  At  the  beginning  of  the  disease  there  is  usually  sharp  pain,  referred 
to  the  nipple  or  axilla,  increased  on  deep  inspiration.  As  the  effusion  increases 
the  pain  diminishes  or  disappears.  Cough  may  be  present  or  absent.  The 
difficulty  in  respiration  varies  with  the  quantity  of  the  exudate.  The  disease 
often  gets  wTell  by  absorption  of  the  fluid.  In  some  cases  a  serous  exudate  may 
be  present,  examination  of  wdiich  may  show  the  presence  of  the  pneumococcus, 
or  of  pus-producing  organisms.  In  these  cases  the  effusion  may  later  become 
purulent.  Sometimes  aspiration  near  the  bottom  of  the  pleural  sac  may  with- 
draw sero-pus,  aspiration  at  higher  level  having  shown  the  presence  of  clear 
fluid. 

Empyema. — A  purulent  inflammation  of  the  pleura  may  originate  in  many 
ways,  some  of  which  have  been  indicated.  When  the  condition  follows  a  pneu- 
monia, a  wound  of  the  thorax,  perforation  of  a  tuberculous  cavity  into  the 
pleura,  a  purulent  mediastinitis,  or  perforation  of  a  carcinoma  of  the  esophagus, 
a  subphrenic  abscess,  or  a  purulent  peritonitis,  or  occurs  in  the  course  of  a 
severe  general  sepsis  or  pyemia,  the  cause  is  not  far  to  seek.  In  other  in- 
stances, the  existence  of  a  purulent  focus  which  cannot  be  located,  or  infection 
through  organisms  existent  in  the  blood,  may  be  offered  in  explanation.  The 
character  of  the  organisms  present  should  be  identified,  if  possible,  by  stained 
smears  of  the  pus  and  by  cultures.  For  the  purpose  of  obtaining  pus  for 
examination,  a  sterile  hypodermic  syringe  and  a  long  needle  may  be  introduced 
in  the  fifth  or  sixth  space  in  the  axillary  line.     The  signs  and  symptoms  of 


DISEASES   OF   THE   PLEURA  657 

empyema  are  those  already  described  as  present  when  the  pleura  contains  free 
fluid,  to  which  are  added  the  symptoms  of  a  more  or  less  pronounced  sepsis. 
There  is  fever  and  prostration,  sometimes  a  chill,  loss  of  appetite,  rapid  emacia- 
tion, etc.  (See  Septic  Diseases.)  In  a  certain  number  of  cases  of  pleuritic  effu- 
sion of  the  purulent  variety,  rarely  in  the  sero-fibrinous  form,  and  nearly  always 
upon  the  left  side,  the  thoracic  wall  over  the  area  occupied  by  the  effusion  pul- 
sates synchronously  with  the  heart.  This  sign  may  also  be  present  as  an  exter- 
nal pulsation  in  empyema  necessitatis.  When  empyema  follows  pneumonia,  the 
signs  and  symptoms  usually  do  not  develop  until  some  days  after  the  fever 
of  the  pneumonia  has  subsided.  The  pneumococcus  is  found  in  the  pus,  some- 
times associated  with  pyogenic  forms. 

In  many  cases,  empyema  develops  from  a  preexistent  sero-fibrinous  exudate ; 
in  these,  the  alteration  from  a  serous  to  a  purulent  exudate  may  be  gradual 
and  not  marked  by  any  sudden  change  in  the  character  of  the  physical  signs 
or  general  symptoms.  There  may  be  little  or  no  cough  or  pain.  The  patients, 
especially  children,  have  wider  daily  ranges  of  temperature,  they  become  weaker, 
markedly  anemic,  and  often  have  profuse  sweats.  In  children,  loud  bronchial 
breathing  over  the  fluid  is  not  uncommon.  The  empyema  caused  by  the  pus- 
producing  organisms  alone  occurs  from  wounds  of  the  pleura,  and  in  the  course 
of  severe  infectious  diseases ;  pleuritis  complicating  scarlet  fever  and  typhoid 
fever  is-  usually  purulent,  or  as  a  complication  of  general  or  local  septic  proc- 
esses of  any  sort.  Sometimes  by  direct  extension  through  the  diaphragm  from 
the  belly,  or  from  a  neighboring  purulent  focus  in  the  lung,  the  mediastinum, 
etc.  Sometimes  as  a  metastatic  infection  through  the  blood  or  lymph  current. 
The  course  of  the  disease  is  apt  to  be  more  severe  and  dangerous  to  life  than 
is  the  case  with  pneumococcus  infections  of  the  pleura. 

Putrid  Empyema. — Putrid  empyema  occurs  when  open  wounds  of  the 
pleura,  notably  in  the  presence  of  hemothorax,  are  infected  with  saprophytes 
alone,  or  in  conjunction  with  pyogenic  organisms.  An  ulcerating  carcinoma  of 
the  gullet ;  an  abscess  or  gangrene  of  the  lung,  which  perforates  the  pleura ; 
or  a  process  having  its  origin  in  traumatic  or  pathological  perforation  of  the 
stomach  or  intestine,  may  result  in  this  form  of  empyema.  The  pus  has  a  stink- 
ing putrid  quality.  The  constitutional  symptoms  are  those  of  combined 
sapremia  and  sepsis.     The  prognosis  is  grave. 

Tuberculous  Pleuritis. — Tuberculous  pleuritis  occurs  as  the  result  of 
infection  of  the  pleura  from  tuberculous  foci  in  the  lung;  as  a  part  of  a  gen- 
eral miliary  tuberculosis ;  as  an  infection  from  tuberculosis  of  the  ribs,  sternum, 
and  vertebrae  The  effusion  may  be  serous,  sero-sanguinolent,  or  purulent. 
Pyopneumothorax  is  not  uncommon.  The  presence  of  Mood  is  strongly  sug- 
gestive of  tuberculosis  or  of  malignant  disease.  The  recognition  of  tubercle 
bacilli  in  the  serous  and  sero-sanguinolent  cases  is  sometimes  easy,  sometimes 
difficult.  If  they  are  not  found  by  the  persistent  use  of  the  centrifuge  and 
staining  and  examination  of  numerous  smears,  inoculation  of  guinea  pigs  may 

be  successful.     In  mixed  infections  by  tubercle  bacilli  and  pyogenic  organ- 
43 


658  THE   THORAX 

isms,  animal  inoculations  often  fail,  the  animals  frequently  dying  of  septic 
infection. 

Noninfectious  Effusions  in  the  Pleural  Cavity. —  Hydrothorax. — The  dis- 
eases of  the  heart  and  kidneys  associated  with  profound  circulatory  disturb- 
ances, and  cachexias  of  various  kinds,  may  he  associated  with  watery  effusions 
in  the  pleural  cavity,  usually  bilateral.  They  are  seldom  treated  surgically. 
Tapping  and  aspiration  are  sometimes  of  temporary  benefit. 

Hemothorax. — Aside  from  trauma,  hemothorax  may  occur  from  rup- 
tured aneurisms ;  or  ulceration  of  vessel  walls,  caused  by  the  pressure  of  for- 
eign bodies,  tuberculous,  cancerous,  or  other  ulceration.  The  signs  and  symp- 
toms have  been  described  under  Injuries  of  the  Thorax. 

Chylothorax. — Open  wounds  or  subcutaneous  lacerations  of  the  thoracic 
duct  in  the  chest  cavity,  and,  rarely,  ulceration  caused  by  malignant  tumors, 
may  permit  the  escape  and  accumulation  of  chyle  in  the  pleural  cavity.  The 
fluid  is  of  a  creamy  consistence  and  color,  contains  usually  sugar;  exhibits 
under  the  microscope  leucocytes  and  finely  divided  fat  drops.  It  is  to  be  dis- 
tinguished from  an  effusion,  somewhat  resembling  it,  present  in  some  cases  of 
tuberculous  pleuritis,  and  in  carcinoma  of  the  pleura  and  lung.  In  these  con- 
ditions the  fluid  is  of  a  milky  color,  thinner  than  chyle,  seldom  contains  more 
than  a  trace  of  sugar.  Under  the  microscope,  fat  drops,  degenerated  epithelial 
and  round  cells,  granular  material,  and  fragments  of  tumor  or  cheesy  material 
may  be  found. 

Tumors  of  the  Pleura. — Benign  tumors  of  the  pleura  have  been  observed — 
fibroma,  angioma,  osteoma.  Their  presence  is  not  likely  to  be  suspected 
unless  they  grow  to  a  large  size,  cause  dullness  on  percusion,  displacement  of 
the  heart,  etc.  A  needle  thrust  into  such  a  tumor  gives  a  sense  of  resistance 
much  greater  than  that  of  fluid  or  lung  tissue.  Of  the  primary  malignant 
tumors  of  the  pleura,  endothelial  cancer  is  the  most  frequent.  The  pleura 
is  greatly  thickened,  there  is  dullness  on  percussion,  and  feeble  or  absent  breath- 
ing. Aspiration  may  withdraw  blood  or  chocolate-colored  blood-stained  fluid. 
Secondary  malignant  tumors  of  the  pleura,  sarcoma  and  carcinoma,  occur  with 
great  frequency,  as  an  extension  by  continuity  of  structure,  or,  as  a  metastatic 
process,  in  cancer  or  sarcoma  of  the  mamma,  the  thyroid  gland,  the  lung,  the 
mediastinum,  the  liver,  stomach,  intestine,  and  elsewhere.  The  signs  and 
symptoms  are  not  apt  to  be  marked  until  the  intrathoracic  growth  has  attained 
some  size.  The  growth  may  consist  of  disseminated  nodules  or  of  massive 
infiltrations.  Early  symptoms  are  pleuritic  pains.  The  presence  of  an  acces- 
sible primary  growth,  or  a  history  of  its  removal,  together  with  rapidly  pro- 
gressive cachexia  and  absence  of  fever,  will  aid  the  diagnosis.  When  the 
tumor  has  reached  a  considerable  size,  dullness  or  flatness  on  percussion  and 
dyspnea  may  be  present.  Introduction  of  an  aspirating  needle  may  give  the 
sensation  that  the  needle  is  passing  through  a  solid  mass  of  tissue,  or  with- 
draw blood-stained  or  milky  fluid.  Fragments  of  tumor  cannot  usually  be 
extracted  with  the  needle ;  but  a  sensation  of  solid  tumor  being  appreciated  by 


DISEASES    OF   THE   LUNG  659 

the  needle,  a  harpoon  or  punch  may  be  used  to  remove  a  fragment  of  tissue, 
when  doubt  exists  as  to  the  diagnosis. 

Echtnococcus  of  the  Pleura. — Echinoeoccus  of  the  pleura  is  rare  as 
a  primary  condition,  more  common  as  an  invasion  by  continuity  of  structure  in 
echinoeoccus  of  the  abdomen.  The  signs  are  those  of  a  tumor  in  the  thorax — 
limited  dullness  or  flatness.  Sometimes  a  distinctly  localized  bulging  has  been 
noted.  Puncture  may  reveal  the  characteristic  fluid  or  booklets.  (See  Echino- 
eoccus. ) 

Actinomycosis  of  the  Pleura. — Actinomycosis  of  the  pleura  is  usually 
secondary  to  actinomycosis  of  the  lung.  Recognition  of  the  granules  in  the 
sputum  is  necessary  for  a  diagnosis,  unless  perforation  of  the  thoracic  wall 
occurs.      (See  Actinomycosis  of  the  Thoracic  Wall  and  Actinomycosis.) 

DISEASES   OF  THE   LUNG 

Diagnosis  of  the  Surgical  Diseases  of  the  Lung. — In  exceptional  cases  the 
following  affections  of  the  lungs  are  amenable  to  surgical  treatment  by  opera- 
tion :  Abscess  of  the  lung ;  gangrene  of  the  lung ;  bronchiectasis ;  circum- 
scribed areas  of  tuberculosis;  echinoeoccus;  actinomycosis;  tumors  of  the 
lung.  Conditions  favoring  such  a  possibility  are:  (1)  Localization  of  the  dis- 
ease in  a  circumscribed  portion  of  lung  tissue  adjacent  to  the  thoracic  wall  and 
in  an  accessible  locality.  (2)  Adhesions  between  the  affected  portion  of  lung 
and  the  thoracic  wall.  While  in  many  cases  no  absolute  knowledge  that  such 
conditions  exist  is  obtainable  before  opening  the  pleura,  yet  adherent  lung  is 
probable  if  the  disease  is  of  long  duration ;  if  the  affected  portion  of  the  chest 
is  immobile ;  if  the  intercostal  spaces  are  depressed ;  if  the  costal  pleura  is 
found  edematous,  inflamed,  and  thickened.  If  the  process  has  already  invaded 
the  soft  parts  of  the  thoracic  wall,  adhesion  of  lung  at  that  point  may  -be 
assumed.  It  is  believed  by  many  surgeons  that  the  introduction  of  a  trocar 
or  aspirating  needle  through  the  unopened  costal  pleura  in  supposed  pyogenic 
diseases  of  the  lung  is  dangerous,  since  the  lung  tissue  is  so  elastic  that  such 
an  instrument  penetrates  it  with  difficulty.  If  the  adhesions  are  soft,  the  lung 
may  be  pushed  bodily  away  and  at  the  same  time  infectious  material  may  be 
permitted  to  escape  into  the  pleural  cavity.  The  advantage  of  such  introduc- 
tion is  that,  if  the  lung  is  firmly  adherent,  the  needle,  after  its  introduction, 
will  not  move  during  respiration.  Adhesion  is  thereby  demonstrated.  In  any 
event,  it  is  probably  safer  to  unite  the  lung  and  costal  pleura  by  a  series  of 
closely  applied  interrupted  catgut  or  silk  sutures  before  incising  the  costal 
pleura.  The  lung  once  fixed,  the  costal  pleura  may  be  incised,  and  the  lung 
explored  with  suitable  trocars  or  needles.  Palpation  of  the  lung  through  the 
unopened  costal  pleura  stripped  widely  from  the  ribs  is  more  dangerous  and 
less  satisfactory. 

Abscess  of  the  Lung. — Abscess  of  the  lung  may  follow  wounds  of  the  lung — 
stab  and  gunshot ;  pneumonias  of  various  kinds ;  empyema ;  aspiration  of  for- 


660  THE   THORAX 

eign  bodies  into  the  lungs ;  septic  processes  in  the  neighboring  or  in  the  abdom- 
inal viscera  (liver,  intestine,  vermiform  appendix,  peritoneum)  by  direct  ex- 
tension or  through  the  lymph  channels ;  metastatic  abscesses  in  pyemia,  usually 
multiple.  The  pneumococcus,  the  pyogenic  cocci,  staphylococci,  streptococci, 
colon  bacilli,  etc.,  may  be  the  exciting  organisms.  Immediately  following  a 
pneumonia,  or  one  or  other  of  the  conditions  mentioned,  the  diagnosis  of 
abscess  of  the  lung  depends  upon  the  following  symptoms  and  signs.  In  the 
presence  of  septic  fever,  more  or  less  marked,  the  patient,  during  a  fit  of 
coughing,  expectorates  a  considerable  quantity  of  pure  pus.  The  pus  is  usu- 
ally thick  and  creamy,  and  has  a  sweet,  sickening  odor,  but  is  not  putrid. 
It  may  be  yellow,  green,  brown,  chocolate-colored,  prune-  or  plum-juice  colored. 
Under  the  microscope,  in  addition  to  pus  cells — usually  in  a  state  of  fatty 
degeneration — and  fat  drops,  there  are  found  abundant  hematoidin  crystals, 
and  shreds  of  fibrous  and  elastic  tissue  originating  from  the  walls  of  the  pul- 
monary alveoli,  sometimes  containing  pigment ;  these  fragments  may  be  so 
large  that  the  form  of  the  alveoli  is  more  or  less  evident.  Numerous  bacteria, 
to  be  identified  by  staining  and  cultures,  sometimes  fat  and  cholesterin  crys- 
tals. The  hematoidin  crystals  consist  of  ruby-red,  orange-colored,  or  dark- 
brown  rhombic  plates,  and  of  needles  or  bundles  of  needles.  Sometimes  por- 
tions of  such  crystals  may  exist  as  granules  in  the  pus  cells.  The  characteristic 
feature  is  the  occurrence  of  such  crystals  free  in  the  pus. 

The  physical  signs  of  abscess  of  the  lung  are  those  of  consolidation  of  the 
lung.  If,  after  a  large  quantity  of  pus  has  been  expectorated,  the  previously 
dull  or  flat  area  becomes  tympanitic,  it  indicates  that  an  abscess  has  burst 
into  a  bronchus,  and  that  its  contents  have  been  expectorated.  A  repetition  of 
this  series  of  events  still  further  confirms  the  diagnosis.  A  frequent  concomi- 
tant is  empyema.  In  the  given  case  it  may  be  impossible  to  tell  whether  an 
abscess  of  the  lung  or  an  empyema  with  perforation  of  a  bronchus  is  present. 
Absence  of,  or  but  few,  elastic  fibers  in  the  pus  would  favor  the  latter  con- 
dition. The  presence  of  tubercle  bacilli  points  to  the  formation  of  a  tuber- 
culous cavity  rather  than  a  true  abscess.  It  is  to  be  borne  in  mind  that  tuber- 
culous cavities  more  commonly  form  near  the  apex  of  the  lung,  while  abscesses 
are  more  frequent  near  the  base.  A  putrid  odor  indicates  gangrene;  entire 
absence  of  elastic  fibers  indicates,  with  a  suitable  history,  bronchiectasis. 
The  X-rays,  both  the  fluoroscope  and  radiographs,  are  capable  of  furnishing 
valuable  aid  in  the  diagnosis  of  abscess  of  the  lung.  A  tube  of  slight  resistance 
giving  the  greatest  possible  differentiation  of  densities  should  be  used.  If  the 
abscess  is  full  of  pus,  a  dark  shadow  will  be  shown  on  the  fluoroscope  and  a 
light  area  on  the  X-ray  negative.  If  the  abscess  cavity  is  empty,  the  condi- 
tions will  be  reversed. 

Gangrene  of  the  Lung. — Putrid  necrosis  of  lung  tissue  may  take  place  in 
a  previously  healthy  organ  or  in  one  already  the  seat  of  disease.  The  condi- 
tion may  be  circumscribed  or  diffuse.  Predisposing  causes  are  diabetes,  chronic 
alcoholism,  debility  from  old  age,  infectious  diseases,  or  cachexias  of  various 


DISEASES    OF   THE   LUNG  661 

kinds.  The  disease  is  more  common  in  men  than  in  women,  and  occurs  in 
the  right  lung  more  often  than  the  left.  In  the  diffuse  form  an  entire  lohe, 
or  more,  may  be  involved.  Various  forms  of  saprophytic  bacteria  associated 
with  pyogenic  staphylococci  are  regularly  present,  together  with  a  form  resem- 
bling leptothrix  buccalis,  to  which  the  name  leptothrix  pulmonis  has  been  given. 
The  determining  conditions  are,  in  a  large  proportion  of  cases,  ordinary  croup- 
ous pneumonia ;  and  the  aspiration  of  foreign  bodies  into  the  bronchi.  Such 
bodies  may  be  corpora  aliena  of  any  description  accidentally  aspirated,  or  por- 
tions of  broken-down  tumor  tissue  from  carcinomata,  situated  in  the  upper  air 
passages.  Further,  necrotic  tissue  or  pus  from  abscesses  or  suppurative  proc- 
esses of  mucous  membrane  (middle-ear  disease  through  the  Eustachian  tube 
into  the  pharynx,  diphtheria,  etc.).  Putrid  decomposition  of  the  contents  of 
a  tuberculous  cavity  or  bronchiectasis  may  invade  the  walls  of  the  cavity  in 
the  lung  with  the  production  of  gangrene.  Suppurative  or  gangrenous  proc- 
esses of  the  gullet  (carcinoma),  bronchial  glands,  mediastinum,  abdominal 
organs,  which  invade  the  lung.  Metastatic  infection  from  distant  organs,  gan- 
grenous ulcers  of  soft  parts  or  of  bone,  giving  rise  to  septic  emboli  and  thrombi 
which  lodge  in  the  lung,  producing  an  infected  infarct.  Rarely,  simple  em- 
bolism of  the  pulmonary  artery.  Infected  wounds  of  the  lung — contused  and 
lacerated,  as  from  broken  ribs,  stab  and  gunshot  wounds. 

Constitutional  Symptoms  of  Gangrene  of  the  Lung. — The  constitu- 
tional symptoms  of  gangrene  of  the  lung  are  those  of  mixed  sapremic  and 
pyogenic  intoxication,  often  of  a  rapidly  fatal  character,  sometimes  more 
chronic.  The  fever  shows  marked  exacerbations ;  there  are  often  chills,  sweat- 
ing, and  diarrhea ;  absolute  loss  of  appetite,  etc.  The  local  signs  in  the  lung 
are,  at  first,  those  of  consolidation,  more  or  less  marked,  impossible  to  detect 
if  the  gangrenous  areas  are  small  and  disseminated.  When  the  dead  tissue  has 
softened,  coarse  moist  rales  and  amphoric  breathing  are  present  over  the 
affected  area.  By  far  the  most  characteristic  diagnostic  sign  of  gangrene  of 
the  lung  is  the  sputum.  The  patient  coughs  up  daily  a  large  amount  (200  to 
600  c.c.)  of  putrid,  stinking  material;  the  odor  is  that  of  carrion,  and  has  been 
likened  to  the  burned  horns  or  hoofs  of  animals.  The  breath  is  also  horribly 
offensive  in  most  cases.  The  color  of  the  sputum  is  gray,  green,  dirty  greenish- 
brown,  or  may  contain  streaks  of  recent  blood.  Upon  standing,  the  sputum 
soon  separates  into  three  layers :  The  uppermost  layer  is  foamy,  muco-purulent, 
dirty-green  or  brown  in  color,  and  contains  little  masses  of  coherent  muco-pus. 
The  middle  is  watery,  partly  clear  or  cloudy;  little  shreds  and  tags  hang 
down  into  it  from  the  upper  layer.  The  third  layer  consists  of  pus,  containing 
much  black  or  green  broken-down  lung  tissue,  in  shreds  and  small  masses,  often 
recognizable  as  containing  elastic  fibers  under  the  microscope.  Small,  partly 
decomposed  blood  clots ;  further,  larger  or  smaller  semisolid  "  Dittrich's 
plugs,"  as  large  as  a  pea  or  bean,  of  a  yellow  or  green  color,  consisting 
of  granular  detritus,  bacteria  of  various  kinds,  fat  crystals,  and  pigment 
granules.      The  differential  diagnosis  from  the  sputum  of  putrid   bronchitis 


662  THE   THOEAX 

is  to  be  made  by  the  absence  of  fragments  of  lung  tissue  in  this  latter 
condition. 

Traube  distinguished  three  conditions  necessary  for  a  diagnosis  of  gangrene 
of  the  lung:  (1)  The  physical  signs  observed  from  day  to  day,  indicating  the 
rapid  formation  of  a  cavity  in  the  lung;  (2)  the  characteristic  sputum  con- 
taining elastic  fibers;  (3)  the  presence  of  Dittrich's  plugs.  The  complications 
of  gangrene  of  the  lung  are  pyemia ;  perforation  of  the  gangrenous  cavity  into 
the  pleura  (with  putrid  pyopneumothorax),  mediastinum,  abdomen;  adhesion 
to  and  perforation  of  the  chest  wall,  with  the  formation  of  an  emphysematous 
gangrenous  process  of  the  thoracic  wall,  abscess  of  the  brain,  and  hemoptysis. 
If  the  gangrenous  area  is  small,  and  does  not  empty  itself  into  a  bronchus,  so 
that  the  characteristic  expectoration  and  odor  are  absent,  the  diagnosis  cannot 
be  made.  The  prognosis  of  the  disease  is  so  unfavorable  that  operative  treat- 
ment is  justifiable  when  any  hope  exists  of  reaching,  opening,  and  draining 
the  focus.  In  order  to  succeed,  the  operation  should  be  done  as  soon  after  the 
diagnosis  is  made  as  possible. 

Bronchiectasis. — Sacculated  dilatations  of  the  bronchi  only  can  be  treated 
surgically,  other  forms  cannot.  (For  the  pathology,  see  works  on  general 
medicine.) 

Symptoms. — There  is  a  history  of  chronic  bronchitis ;  sooner  or  later  char- 
acteristic symptoms  appear.  The  patients  are  subject  to  periodic  attacks  of 
violent  coughing,  which  may  occur  one  or  several  times  during  the  day,  often 
in  the  morning.  The  coughing  results  in  the  expectoration  of  a  large  quan- 
tity of  pus  or  muco-pus,  amounting  in  some  cases  to  a  pint  or  more.  The 
sputum  may  or  may  not  have  a  stinking  or  a  putrid  odor ;  on  standing  it  sepa- 
rates into  an  upper  clear  watery  layer,  and  a  lower  layer  of  pus,  bacteria,  and 
detritus,  fat,  etc.  Blood  may  be  present  in  greater  or  less  quantity.  Hemor- 
rhages are  not  very  rare.  Fever  is  due  only  to  complications.  The  general 
health  suffers,  the  patients  have  chronic  cyanosis,  the  fingers  become  clubbed, 
the  nails  curved.  Associated  interstitial  pneumonia  and  contraction  of  the  lung 
causes  depressions  in  the  chest  and  deformity  of  the  spine.  Emphysema  of 
the  other  lung  is  common.  Infection  of  the  lung  surrounding  the  cavity  may 
lead  to  abscess  and  gangrene.  Amyloid  degeneration  of  the  liver  and  kidneys 
may  occur.  The  physical  signs  are  sometimes  clearly  defined,  sometimes  not. 
In  typical  cases  dullness  alternates  with  tympanitic  or  cracked-pot  resonance, 
according  as  the  cavity  is  filled  or  empty.  Auscultation  may  give  amphoric 
or  bronchial  breathing.  Rales  will  be  present  or  absent,  according  to  the  con- 
tents of  the  cavity.  If  the  presence  of  a  single  suitably  placed  cavity  can  be 
assumed,  its  operative  drainage,  or  resection  of  a  portion  of  lung  has,  in  some 
cases,  relieved  the  symptoms  and  improved  the  general  condition. 

Tuberculosis  of  the  Lungs. — The  surgery  of  tuberculosis  of  the  lung  has 
hitherto  been  confined  to  resection  of  circumscribed  portions  of  lung  tissue  in 
cases  where  the  disease  was  confined  to  the  apex  and  to  the  drainage  of  tuber- 
culous cavities.     (For  the  diagnosis  of  tuberculosis  of  the  lungs  the  reader  is 


DISEASES   OF   THE   LUNG  663 

referred  to  works  on  general  medicine.)  The  fact  that  in  a  few  cases  resec- 
tion of  a  tuberculous  focus  of  lung  lias  resulted  in  euro,  is  encouraging,  but  it 
must  always  be  difficult  to  know  when  such  a  focus  is  solitary.  The  drainage 
of  tuberculous  lung  cavities  as  a  palliative  measure  may  be  justifiable  if  the 
retention  of  its  contents  is  a  serious  element  in  the  case. 

Echinococcus  of  the  Lung. — Echinococcus  is  rare  in  America.  In  those 
countries  where  the  disease  is  common,  the  lung  is,  next  to  the  liver,  its  most 
frequent  site.  Out  of  one  hundred  and  seventy-six  cases  collected  by  Madelung, 
it  occurred  nineteen  times  in  the  lung.  The  signs  and  symptoms  are  readily 
mistaken  for  those  of  phthisis;  sometimes  for  tumor  of  the  lung,  with  effusion 
into  the  pleura,  or  for  ordinary  pleuritic  effusion.  There  is  cough  with  muco- 
purulent sputum,  from  time  to  time  tinged  with  blood,  pain  in  the  chest,  loss 
of  flesh  and  strength,  dyspnea  from  pressure.  If  the  cyst  is  large  there  may 
be  bulging  of  the  chest  wall.  Percussion  gives  flatness  over  the  cyst,  and 
auscultation,  absence  of  breathing  or  feeble  bronchial  breathing;  the  line  of 
flatness  may  be  irregular.  If  the  tumor  bursts  into  a  bronchus,  the  patient 
may  choke  to  death,  or  expectorate  clear  watery  fluid  and  hooklets,  from  which 
the  diagnosis  can  be  made.  Cure  has  followed  from  shriveling  of  the  cyst; 
in  other  cases  abscess  or  gangrene  of  the  lung.  If  the  thoracic  wall  is  per- 
forated, cysts  may  be  discharged  through  an  opening  in  the  skin.  Rupture 
into  the  pleura  may  give  rise  to  pyopneumothorax  if  the  rupture  communi- 
cates with  a  bronchus.  In  general,  the  picture  closely  resembles  that  of  phthisis 
without  the  presence  of  bacilli.  Puncture  of  the  cyst  with  an  aspirating  needle 
withdraws  clear  watery  fluid  containing  but  little  albumen  and  a  notable  quan- 
tity of  sodium  chlorid ;  in  some  cases  hooklets  are  discoverable.  The  diagno- 
sis has  rarely  been  made  until  characteristic  elements  have  either  been  dis- 
charged externally  through  the  skin  or  coughed  up.  X-ray  examination  would 
very  probably  show  a  definite  shadow,  but  its  nature  would  be  unknown. 

Actinomycosis  of  the  Lung. — (For  the  diagnosis,  see  Actinomycosis.)  Hith- 
erto surgical  treatment  has  availed  but  little. 

Tumors  of  the  Lung. — Carcinoma  of  the  Lung. — Primary  cancer  is  rather 
rare.  Secondary  cancer  is  very  common.  Primary  growths  are  confined  to 
one  lung,  and  are  solitary.  Secondary  tumors  usually  involve  both  lungs,  and 
are  multiple  and  disseminated.  Primarily,  both  cylinder-celled  and  squamous 
carcinoma  occur;  the  former  is  more  common.  The  diagnosis  of  the  sec- 
ondary forms  is  usually  plain.  The  occurrence  of  pulmonary  disease  follow- 
ing the  removal  of  a  cancer  of  the  breast,  the  rectum,  the  stomach,  etc.,  is 
always  suggestive.  The  diagnosis  of  primary  cancer,  on  the  other  hand,  is 
difficult  or  impossible  at  a  time  when  operative  removal  can  be  of  real  value. 
The  disease  occurs  in  advanced  life.  If  the  tumor  has  a  central  location,  and 
is  covered  by  a  layer  of  healthy  lung  tissue,  no  symptom  may  occur  until  it 
has  reached  a  large  size.  If  the  tumor  is  superficial,  the  signs  are  those  of 
a  circumscribed  area  of  consolidated  lung.  There  is  bronchitis,  sometimes 
with  "prune-juice"  expectoration;  pain  in  the  side,  loss  of  flesh  and  strength. 


664  THE   THORAX 

There  may  be  pleuritic  effusion,  and  in  a  moderate  number  of  cases  such  effu- 
sion may  contain  blood  or  numerous  cells,  or  groups  of  cells  of  various  shapes 
and  sizes  with  large  nuclei.  The  occurrence  of  effusion  is  the  exception  rather 
than  the  rule.  Firm  adhesion  to  the  costal  pleura  is  more  commonly  present. 
Expectoration  of  tumor  cells  or  tumor  masses  renders  the  diagnosis  certain. 
Hemoptysis  is  not  uncommon.  The  use  of  a  punch  to  obtain  a  portion  of  tissue 
for  examination  is  rather  dangerous  on  account  of  bleeding.  The  subsequent 
history  is  that  of  intrathoracic  pressure  and  rapidly  progressive  cachexia.  Sec- 
ondary involvement  of  supraclavicular  glands  aids  in  the  diagnosis.  The 
physical  signs  of  consolidated  lung  continue  to  spread  as  the  disease  advances. 
Operation  has  not  as  yet  been  of  benefit  in  primary  carcinoma  of  the  lung. 

Sabcoma  of  the  Lung. — Sarcoma  of  the  lung  is  exceedingly  common  as  a 
secondary  growth.  In  such  cases  the  diagnosis  is  not  difficult.  Primary  sar- 
comata are  more  rare  than  carcinomata.  Lympho-sarcoma  appears  to  be  the 
most  common  form.  The  disease  occurs  as  a  diffuse  process  originating  in  the 
lymphoid  tissue  of  the  lung  in  the  form  of  disseminated  nodules  and  areas  of 
tumor  tissue  following  the  course  of  the  lymph  vessels  of  the  bronchi.  The 
disease  is  characterized  by  a  rather  slow  growth  and  by  the  formation  of  sec- 
ondary tumors,  by  direct  extension,  and  by  metastasis  in  the  abdominal  organs. 
This  form  occurs  with  peculiar  frequency  among  the  workers  in  the  cobalt 
mines  of  Schneeberg,  and  affects  especially  the  men  who  have  worked  contin- 
uously for  years  inhaling  the  irritating  dust  of  the  mines.  The  tumors  often 
reach  a  very  large  size  before  death  occurs.  Spindle-celled,  giant-celled,  and 
mixed  forms  of  sarcoma  are  less  common,  and  occur  as  single  nodular  tumors 
of  the  lung.  The  signs  and  symptoms  of  sarcoma  of  the  lung  do  not  materially 
differ  from  those  of  carcinoma.  Stridulous  breathing  is  said  to  be  more  com- 
mon in  sarcoma.  Breaking  down  of  tumor  tissue  and  expectoration  of  tumor 
cells  or  masses  is  not  likely  to  occur  in  sarcoma.  Generalized  metastasis  is  more 
common  in  sarcoma  than  in  carcinoma.  The  massive  tumors  are  easily  recog- 
nizable by  means  of  the  X-rays.  Death  occurs  from  pressure  on  the  heart, 
the  recurrent  nerves,  the  trachea,  from  exhaustion,  gangrene  of  the  lung,  pneu- 
monia, or  fatal  metastasis,  as  in  the  brain. 

Benign  Tumoes  of  the  Lung. — Various  forms  of  benign  tumors  have 
been  observed  from  time  to  time  in  the  lung.  Lipoma,  fibroma,  enchondroma, 
osteoma,  dermoid  cysts,  endothelioma — the  last  usually  secondary  to  endo- 
thelioma of  the  pleura.  They  are  to  be  regarded  as  pathological  curiosities.  If 
large,  they  may  cause  dyspnea  or  other  pressure  symptoms.  Dermoids  have 
been  known  to  burst  into  the  bronchus  with  the  expectoration  of  hair.  There 
is  no  means  at  present  whereby  a  definite  differential  diagnosis  can  be  made. 

THE   MEDIASTINUM 

A  few  cases  of  primary  suppuration  in  the  mediastinum  have  been  ob- 
served.    In  most  cases  infection  has  been  due  to  wounds  and  to  extension  of 


THE    MEDIASTINUM  665 

suppuration  processes  from  neighboring  structures — the  neck,  the  larynx,  the 
trachea,  the  pharynx,  the  esophagus,  the  vertebra',  the  pleura,  the  pericardium, 
the  lungs,  and  the  bronchial  glands.  (See  the  Connective-tissue  Planes  of  the 
Neck  and  Inflammations  of  the  Neck.)  Also  from  infectious  processes  of 
the  ribs  and  sternum ;  not  infrequently  from  the  ulceration  of  foreign  bodies 
in  the  trachea  and  esophagus  or  to  ulceration  of  a  carcinoma  of  the  gullet  and 
as  a  metastatic  process  in  acute  infectious  diseases.  The  inflammations  of 
the  mediastinum  may  be  acute  or  chronic. 

Acute  Suppurative  Mediastinitis. — The  most  marked  symptom  is  pain, 
referred  to  a  point  behind  the  sternum,  sometimes  radiating  into  the  shoulders ; 
or  pain  in  the  back,  which  may  follow  the  course  of  the  intercostal  nerves. 
Tenderness  over  the  sternum  indicates  rather  that  the  focus  is  in  the  anterior 
portions  of  the  mediastinum ;  much  pain  referred  to  the  back,  that  the  tissues 
in  front  of  the  spine  are  involved.  The  original  focus,  if  that  be  known,  may 
point  to  the  seat  of  the  pus. 

Fever. — The  fever,  prostration,  and  other  symptoms  of  acute  sepsis  are 
present. 

Pressure  Symptoms. — Dyspnea,  a  sense  of  oppression  in  the  chest,  a  rapid, 
irregular  heart  action — in  some  cases  a  pulsus  paradoxus,  which  grows  feeble 
or  intermits  during  inspiration — develop  and  increase  in  severity  as  the  pus 
accumulates  and  spreads.  The  abscess  may  point  between  the  ribs  in  front, 
or  in  the  supraclavicular  triangle  of  the  neck ;  and  a  guide  for  incision  may 
thus  be  obtained.  In  other  instances  the  pus  may  rupture  into  the  trachea; 
pericardium,  or  pleura.  Aspirating  needles  may  be  introduced  in  suspected 
regions.  In  most  cases  the  situation  of  the  original  focus  will  determine 
whether  the  opening  is  to  be  made  in  front  or  posteriorly,  alongside  the  spinal 
vertebra?. 

Chronic  Mediastinitis. — Chronic  mediastinitis  runs  a  less  stormy  course. 
The  pain  is  less  severe,  the  constitutional  symptoms  less  marked ;  fever  may 
be  absent.  The  origin  of  chronic  mediasinitis  is  often  in  carious  tuberculous 
ribs  or  sternum,  sometimes  in  tuberculous  bronchial  glands.  Pressure  symp- 
toms may  be  present,  as  in  acute  cases. 

Tumors  of  the  Mediastinum. — Primary  tumors  of  the  mediastinum,  whether 
benign  or  malignant,  are  comparatively  rare.  Secondary  tumors  are  sufficiently 
common,  due  to  extension  from  neighboring  structures — esophagus,  lungs,  pleu- 
ra, sternum,  ribs,  thyroid  gland.  The  benign  tumors  produce  symptoms  by 
pressure,  the  malignant  tumors  by  pressure  and  by  the  invasion  and  destruction 
of  surrounding  tissues.  The  following  primary  benign  tumors  have  been 
observed  in  small  numbers:  lipoma,  fibroma,  dermoids,  echinococcus,  retro- 
sternal goiter.  The  retrosternal  glandular  masses  common  in  Hodgkin's  dis- 
ease produce  the  symptoms  of  mediastinal  tumors.  Both  carcinoma  and  sar- 
coma may  originate  in  the  mediastinum ;  they  are  more  numerous  than  the 
benign  growths ;  they  are  believed  to  originate  especially  in  the  remains  of 
the  thvmus,  in  the  bronchial  glands  and  the  walls  of  the  bronchi. 


666 


THE   THOEAX 


The  symptoms  produced  by  the  primary  tumors  of  the  mediastinum  are 
chiefly  those  due  to  pressure.  They  are  dyspnea,  from  pressure  upon  the 
lungs,  the  bronchi,  and  trachea ;  change  of  voice,  from  pressure  on  one  recur- 
rent nerve:  serious  dyspnea,  from  pressure  on  both,  with  paralysis  of  both 


Fig.  239. — Anettrism  of  the  Arch  of  the  Aorta. 
(New  York  Hospital,  sen-ice  of  Dr.  Frank  Hartley.) 

vocal  cords  observable  by  laryngoscopy ;  paralysis  of  the  diaphragm,  by  pressure 
on  the  phrenic ;  a  slow  pulse,  by  irritation  of  the  vagi ;  a  rapid  pulse,  by  paral- 
ysis of  the  same;  precordial  distress  and  irregular  heart  action,  by  pressure 
on  the  heart:  dysphagia,  by  pressure  on  the  esophagus.  As  the  tumor  grows 
larger,  bulging  and  deformity  of  the  thoracic  wall  may  occur.  The  tumor 
may  grow  between  the  ribs  and  appear  externally  or,  if  malignant,  infiltrate 
and  destroy  these  bones  and  appear  beneath  the  skin.  The  veins  of  the  front 
of  the  chest  and  back  may  be  dilated.     There  may  be  localized  areas  of  edema. 


DISEASES    OF   THE   PERICARDIUM  667 

The  tumor  may  appear  in  the  supraclavicular  fossa  or  episternal  region.  The 
trachea  may  become  adherent  to  the  growth,  if  it  be  malignant,  and  the  larynx 
then  no  longer  moves  during  the  act  of  swallowing.  The  lymph  nodes  at  the 
root  of  the  neck  and  in  the  axilla  become  enlarged  in  malignant  cases.  After 
the  tumor  has  perforated  the  thoracic  "wall  it  may  pulsate;  such  pulsation  may 
be  due  to  its  own  vascularity  or  to  transmitted  pulsation  from  the  heart  or 
aorta.  A  differential  diagnosis  from  aneurism  may  be  difficult.  Evidences 
of  valvular  or  other  heart  lesion  would  favor  aneurism ;  marked  displacement  of 
the  apex  beat,  a  tumor.  The  X-rays  would  show  a  more  or  less  centrally 
placed  shadow  if  the  tumor  were  of  considerable  size. 

The  benign  tumors  may  exist  for  a  long  period  without  destroying  life. 
The  malignant  tumors,  by  their  more  rapid  and  destructive  growth,  run  a  much 
shorter  course.  The  secondary  tumors  of  the  mediastinum  produce  the  same 
symptoms  as  the  primary.  They  are,  of  course,  all  malignant ;  among  them 
may  be  included  the  glands  of  Hodgkin's  disease,  carcinoma  following  cancer 
of  the  mamma,  and  involvement  of  the  mediastinum  by  tumors  of  the  lung  and 
pleura.  Gummata,  producing  symptoms  of  tumor  in  the  mediastinum,  have 
been  observed. 

ANEURISM   OF   THE   AORTA 

Aside  from  ordinary  methods  of  examination  lying  entirely  in  the  field  of 
internal  medicine,  the  X-rays  are  a  valuable  aid  in  diagnosis.  Very  good 
pictures  of  aortic  aneurisms  can  be  obtained,  and  the  shadows  cast  on  the 
fluoroscope  are  often  distinct. 

DISEASES   OF   THE   PERICARDIUM 

Effusions  into  the  pericardium  may  be  serous,  purulent,  or  bloody.  (For 
the  effusions  due  to  trauma,  see  Injuries  of  the  Pericardium.)  Simple  serous 
effusions  occur  from  profound  circulatory  disturbances  (cardiac  and  renal  dis- 
ease). Acute  inflammatory  effusions  may  be  serous,  sero-fibrinous,  or  purulent. 
They  occur  as  complications  of  infectious  diseases — pneumonia,  typhoid  fever, 
acute  articular  rheumatism,  etc.  Many  are  tubercular,  and  run  a  more  chronic 
course.  (For  further  details,  see  works  on  general  medicine.)  When  the 
effusion  is  excessive,  or  purulent,  the  condition  may  be  treated  surgically  with 
great  benefit.  The  signs  and  symptoms  rendering  surgical  interference  desira- 
ble are  dyspnea;  serious  interference  with  the  action  of  the  heart,  as  already 
detailed  under  Injuries  of  the  Pericardium ;  marked  increase  of  heart  dull- 
ness ;  the  presence  of  pus,  or  of  pyogenic  germs,  or  the  pneumococcus  in  the 
effusion,  as  determined  by  hypodermic  puncture.  As  in  pleuritic  effusions, 
a  fluid  at  first  serous  may  subsequently  become  purulent.  When  the  effusion 
contains  micro-organisms,  free  drainage  is  much  to  be  preferred  to  puncture. 


CHAPTER    XXII 
THE   BREAST 

ANATOMICAL  AND   PHYSIOLOGICAL  CONSIDERATIONS 

{Partly  adapted  from  MerJcel) 

The  mammary  gland  reaches  its  full  development  only  in  the  female.  In 
well-developed  virgins  the  breast  extends  upon  the  thorax  from  the  third  to  the 
sixth  rib,  rarely  lower,  resting  upon,  and  to  a  great  extent  covering,  the  pec- 
toralis  major  muscle.  The  contour  of  a  perfect  breast,  as  viewed  from  an 
artistic  standpoint,  shows  no  fold  at  its  lower  border,  and  is  nearly  hemi- 
spherical ;  commonly,  gravity  causes  the  lower  half  to  be  fuller  and  rounder 
than  the  upper.  The  nipple  is  directed  a  little  outward  in  the  virgin.  During 
menstruation  the  breast  usually  increases  in  size;  at  this  time  the  gland  may 
be  a  little  tender;  a  subjective  sensation  of  fullness  is  present.  A  moderate 
asymmetry  in  the  size  of  the  two  breasts  is  not  uncommon.  In  females  who  are 
poorly  nourished  or  overfat,  the  breasts  are  often  notably  pendant.  This  is 
almost  invariably  the  case  after  a  woman  has  borne  a  child.  The  breast  does 
not  regain  its  firm  consistence  and  rounded  shape,  but  remains  more  or  less 
pendant  and  flabby. 

The  skin  of  the  breast  is  thin  and  smooth ;  subcutaneous  veins  are  often 
visible.  After  pregnancy,  linea;  albicantes,  such  as  occur  upon  the  abdomen, 
are  often  to  be  observed.  The  skin  of  the  breast  is  movable  over  the  underly- 
ing gland,  but  during  lactation  it  can  no  longer  be  raised  into  folds.  The 
mobility  of  the  skin  is  important  from  a  diagnostic  point  of  view.  It  is  early 
lost  in  malignant  tumors  of  the  breast,  as  will  be  noted  later.  Xormally  the 
breast  is  quite  movable  on  the  pectoralis  beneath,  the  fascial  attachments  being 
less  firm  than  those  to  the  skin.  The  skin  of  the  nipple  and  areola  is  not 
smooth,  but  quite  uneven,  rough,  and  ridged.  At  the  apex  of  the  nipple  are  the 
minute  orifices  of  fifteen  to  twenty  milk  ducts.  The  areola  contains  numerous 
sebaceous  and  sweat  glands.  The  sebaceous  glands  produce  little  prominences 
on  the  surface.  The  color  of  the  nipple  and  areola  is  pink  and  red  in  blondes 
and  brown  in  brunettes.  This  pigmentation  is  increased  during  pregnancy  and 
lactation,  and  is  permanent.  The  skin  of  the  nipple  and  areola  is  thin  and 
delicate;  nursing  easily  causes  excoriations  and  fissures,  through  which  infec- 
tion often  takes  place,  with  the  production  of  abscess,  ervsipelas,  etc.  The 
668 


ANATOMICAL   AND   PHYSIOLOGICAL   CONSIDERATIONS  669 

nipple  is  permanently  increased  in  size  by  lactation.  During  pregnancy  from 
five  to  fifteen  accessory  milk  glands  are  developed  in  the  skin  of  the  areola; 
they  form  small,  rounded  or  flat  prominences  in  the  skin,  easily  recognized 
(Montgomery's  glands).  The  nipple  and  areola  contain  numerous  unstriped 
muscle  fibers;  upon  mechanical  irritation,  such  as  nursing  or  other,  these 
fibers  contract  and  cause  the  nipple  to  become  longer  and  more  prominent. 
The  mammary  gland  is  embedded  in  the  subcutaneous  fat  of  the  breast.  Mor- 
phologically the  gland  is  derived  from  the  skin,  and  probably  represents  a  con- 
geries of  sebaceous  glands.  The  gland  in  well-nourished  virgins  is  separated 
from  the  pectoralis  muscle  by  a  considerable  layer  of  fat. 

The  virgin  breast  is  in  reality  largely  composed  of  fat,  the  gland  itself  being 
quite  small  and  extending  only  a  little  way  beyond  the  border  of  the  areola. 
Its  shape  is  somewhat  irregular;  sometimes  the  bulk  of  the  gland  lies  be- 
low the  nipple  and  tapers  off  above.  The  milk  ducts  divide  dichotomously, 
and  the  ultimate  branches  end  in  areas  of  still  imperfectly  developed  gland 
tissue.  The  ducts  and  lobules  remain  distinct  and  do  not  anastomose  one  with 
another.  The  ultimate  branches  are  surrounded  by  a  considerable  quantity 
of  firm  connective  tissue  rich  in  nuclei,  having  a  hyaline  appearance,  and 
different  in  character  from  the  fibrous  supporting  stroma  between  the  lobules. 
On  section  the  gland  looks  like  firm  homogeneous  connective  tissue,  which  fades 
off  into  the  surrounding  structures ;  separate  lobules  cannot  be  distinguished 
with  the  naked  eye.  On  the  anterior  surface  of  the  gland  numerous  bundles 
and  planes  of  connective  tissue  pass,  to  be  attached  to  the  skin,  the  spaces 
between  them  being  filled  with  fat;  beneath  the  areola  there  is  no  fat. 

Pregnancy  causes  the  gland  to  develop  its  full  functional  activity.  The 
true  secreting  acini  increase  in  size  and  number.  The  milk  ducts  dilate,  and 
before  their  entrance  into  the  nipple  considerable  fusiform  cavities  are  formed 
— the  "  sinus  ductuum  lactiferorum."  The  fat  and  connective  tissue  are  dimin- 
ished in  proportion  as  the  glandular  tissue  is  increased.  The  lobules  of  the 
gland  become  distinctly  palpable,  and  are  readily  differentiated  on  section. 
Beneath  the  breast  the  fat  between  the  gland  and  the  muscle  entirely  disap- 
pears. While  the  gland  assumes  a  somewhat  hemispherical  shape,  three  pro- 
jections occur  on  its  periphery :  an  inner,  a  lower  and  outer,  and  an  upper  and 
outer;  this  last  reaches  to  and  along  the  border  of  the  pectoral  muscle  well  up 
into  the  axilla  in  proximity  to  the  axillary  lymph  nodes,  and  can  be  felt  as  a 
tender  cord  extending  in  that  direction.  This  projection  is  especially  to  be 
borne  in  mind  in  relation  to  inflammations  and  tumors  of  the  breast.  Lacta- 
tion finished,  the  breast  does  not  return  to  its  virgin  state.  The  gland  remains 
large,  the  lobules  palpable,  and  the  projection  into  the  axilla  is  permanent; 
it  should  be  included  in  the  operative  removal  of  the  entire  breast.  This  more 
or  less  isolated  portion  of  gland  tissue  may  be  the  starting  point  of  a  new 
growth.  The  epithelial  lining  of  the  acini  of  the  sometime  active  gland  re- 
mains as  cylindrical  epithelium,  and  its  abnormal  proliferation  is  the  starting 
point  of  cancer. 


670  THE   BREAST 

Blood  Supply  of  the  Breast. — The  blood  supply  of  the  breast  is  derived  from 
the  perforating  arteries  of  the  internal  mammary  which  emerge  through  the 
second,  third,  and  fourth  intercostal  spaces ;  the  second  is  the  largest ;  and  from 
the  long  thoracic  and  acromial  thoracic  arteries.  The  deep  veins  accompany 
the  corresponding  arteries.  The  superficial  veins  form  a  network  under  the 
skin,  and  some  of  them  empty  into  the  external  jugular  above  the  clavicle. 
In  general,  the  blood  supply  is  abundant.  The  individual  vessels  are  not 
large,  but  may  be  enormously  increased  in  size  by  malignant  disease,  notably 
sarcoma. 

Lymphatics  of  the  Breast. — The  lymph  vessels  of  the  breast,  and  the  lymph 
nodes  into  which  they  empty,  are  of  especial  interest  in  relation  to  malignant 
disease.  The  lymph  vessels  may  be  divided  into  two  groups:  those  arising 
from  the  gland  and  those  arising  from  the  skin.  The  lymph  vessels  of  the 
gland  follow  the  milk  ducts;  these  unite  to  form  a  plexus  beneath  the  areola, 
joined  also  by  the  lymph  vessels  of  the  skin  of  the  areola  and  of  the  nipple. 
From  this  subareolar  plexus  there  proceed  two  large  lymphatic  trunks,  one 
above,  one  below  the  nipple.  The  first  proceeds  in  a  transverse  direction 
toward  the  axilla ;  the  second  describes  a  semicircular  curve  downward,  to  end 
also  in  the  axilla.  From  the  periphery  of  the  gland  above,  and  below,  two 
smaller  lymphatic  trunks  arise,  which  join  the  other  two  before  reaching  the 
axilla.  The  main  trunks  empty  into  the  lymph  glands  situated  at  the  anterior 
border  of  the  axilla.  The  first  gland  lies  beneath  the  border  of  the  pectoralis 
major,  over  the  third  serration  of  serratus  ma  gnus — i.  e.,  over  the  third  rib, 
sometimes  partly  over  the  third  intercostal  space.  A  well-developed  pectoral 
muscle  may  cover  it  completely.  This  gland  is  commonly  the  one  first  infected 
in  carcinoma  of  the  breast.  According  to  Henle,  the  axillary  lymph  nodes  are 
ten  to  twelve  in  number.  The  superficial  ones  lie  immediately  beneath  the 
fascia.  The  deeper  ones  follow  the  course  of  the  axillary  vein  as  far  as  the 
clavicle. 

According  to  Konig,  "  the  greater  number  of  the  axillary  glands  are 
grouped  around  the  origin  of  the  long  thoracic  and  subscapular  arteries."  A 
-lender  mass  of  fat  containing  lymphatics  lies  also  in  front  of  and  behind  the 
vein.  The  lymph  nodes  of  the  subclavian  triangle  receive  lymph  from  the 
axilla,  and  these  become  infected,  often  quite  early,  in  carcinoma  of  the  breast. 
The  deep  surface  of  the  breast  also  has  lymph  vessels,  which  communicate  with 
the  intercostal  lymphatics  and  thence  with  the  interior  of  the  thorax.  Through 
these  channels  infection  takes  place,  and  masses  of  carcinoma  may  be  found 
not  only  in  the  substance  of  pectoralis  major,  but  in  the  intercostal  spaces, 
quite  early  in  the  disease.  Hence,  the  much  better  results  now  obtained  by 
operation,  since  it  has  come  to  be  a  matter  of  routine  to  remove  both  pectoral 
muscles  in  all  cases  of  carcinoma  mamma?. 

Nerves  of  the  Breast. — The  nerves  of  the  breast  are  derived  from  the  supra- 
clavicular nerves  which  descend  in  front  of  the  clavicle  to  supply  the  skin, 
and   from  the   anterior   and   lateral   perforating  nerves,   derived    from   the   in- 


INJURIES   OF   THE   BREAST  671 

tercostals,  from  the  second  to  the  sixth,  which  supply  the  deeper  portions  of 
the  gland. 

In  childhood  and  np  to  the  time  of  puberty  the  development  of  the  mamma 
is  the  same  in  both  sexes.  In  males  the  development  proceeds  no  further  and 
atrophy  begins  at  about  the  thirtieth  year.  At  the  menopause  the  female 
breast  atrophies.  There  remains  nothing  behind  but  milk  ducts,  connective 
tissue,  and  fat.  The  fat,  if  abundant,  preserves  the  size  and  form  of  the 
breast. 

CONGENITAL   ANOMALIES   OF   THE    BREAST 

Absence  of  the  mammary  gland  (amastia)  is  a  rare  defect,  and  when 
present  is  commonly  associated  with  other  defects  in  the  sexual  apparatus.  It 
sometimes  happens  that  the  glands  remain  in  an  infantile,  undeveloped  state 
in  the  adult  female  (micromastia).  Two  nipples  may  be  present  on  one  breast ; 
the  nipple  may  be  absent.  In  males  the  breasts,  one  or  both,  may  go  on  to 
develop  as  in  women.  The  condition  is  known  as  "  gynecomasty,"  and  is  some- 
times associated  with  sexual  abnormalities,  such  as  undeveloped  testis.  Occa- 
sionally the  breasts  of  female  children  undergo  a  precocious  development ;  this 
may  occur  alone  or  combined  with  an  abnormally  early  development  of  the 
entire  sexual  apparatus.  Supernumerary  breasts  (polymastia)  is  a  not  very 
uncommon  condition.  One  or  several  aberrant  glands  may  be  present;  usually 
there  is  but  one,  situated  below  one  of  the  normal  breasts.  As  many  as  eight 
have  been  observed.  They  usually  occur  along  a  line  drawn  on  the  ventral 
surface  of  the  body  from  the  junction  of  the  upper  extremity  and  the  trunk 
to  the  genitals,  corresponding  to  the  situation  of  the  breast  germs  of  fetal 
mammals  in  general.  They  do  not  have  a  complete  secretory  duct ;  they  may 
become  enlarged  and  painful  during  pregnancy.  In  addition  to  the  above 
situations,  they  have  been  observed  on  the  thigh  or  hip,  on  the  back,  the  deltoid 
region,  in  the  axilla,  and  elsewhere.  Such  glands  may  be  large  or  small,  and 
may  be  mistaken  for  benign  tumors  of  various  kinds,  or  for  lymph  nodes. 

INJURIES   OF   THE  BREAST 

Open  wounds  of  the  breast,  whether  incised,  stab,  or  punctured  wounds, 
present  no  peculiarities.  The  vascularity  of  the  region  favors  rapid  healing 
in  the  absence  of  infection.  Contusions  of  the  breast  often  result  in  marked 
extravasation  of  blood  and  ecchymosis,  which  slowly  disappears.  In  not  a 
few  cases  a  blow,  a  fall,  or  other  similar  injury  to  the  breast  is  followed  by 
the  development  of  carcinoma.  Contusions  of  the  breast  during  the  puerperal 
state  and  lactation  are  more  apt  to  be  followed  by  suppuration  and  abscess 
than  at  other  times.  Burns  of  the  breast  are  sometimes  followed  by  cicatricial 
contraction  and  deformity  of  the  nipple  and  milk  ducts,  such  that  trouble 
from  damming  of  the  milk  after  labor  may  occur,  and  necessitate  weaning,  or 
even  incision. 


672 


THE    BREAST 


DISEASES   OF  THE   BREAST 

Diseases  of  the  Nipple  and  Areola. —  During  lactation,  painful  fissures  and 
excoriations  of  the  nipple,  notably  at  its  base,  are  very  common ;  they  are  read- 
ily recognized.  Their  importance  depends  chiefly  upon  the  fact  that  as  long  as 
they  remain  unhealed  they  form  open  avenues  for  infection  with  pyogenic  or 
other  germs.  They  may  become  the  seat  of  aphtha?.  (See  Diseases  of  the 
Mouth  and  Throat.) 

Depressed  Nipples. — The  nipple  may  form  a  hollow  instead  of  a  projec- 
tion, and  render  nursing  difficult  or  impossible,  but  a  very  unpromising  nipple 
in  a  virgin  may  develop  during  and  after  pregnancy  into  an  efficient  organ. 

Eczema. — Eczema  of  the  nipple  and  areola,  with  the  formation  of  crusts, 
is  usually  due  to  want  of  cleanliness.  If  chronic,  it  may  end  in  epithelioma. 
(See  Paget's  Disease.) 

Syphilis.- — Chancre  of  the  nipple  usually  appears  as  a  juicy-looking  super- 
ficial ulceration  of  the  nipple,  or  as  an  indurated  fissure  at  its  base.  The 
history  of  exposure;  inspection  of  the  infant,  if  the  woman  is  a  wet-nurse;  the 
enlargement  of  the  axillary  glands;  the  occurrence  of  secondary  lesions,  will 
establish  the  diagnosis.  If  much  irritated  or  infected  with  pus  microbes  the 
chancre  may  take  on  an  ecthymatous  character.  Secondary  mucous  plaques 
and  flat  condylomata  may  occur  upon  the  nipple  and  areola.  (See  Syphilis.) 
Gummata. — Gummatous  ulcerations  in  the  vicinity  of  the  nipple  have  the 
same  characters  here  as  elsewhere.      (See  Syphilis.) 

Paget's  Disease  of  the  Nipple  and  Areola. — In  1874,  James  Paget 
first  described  a  chronic  disease  of  the  skin  of  the  nipple  and  areola  which 

began  as  a  moist,  painful  eczema 
with  excoriation  of  the  surface,  or 
as  a  chronic  squamous  eczema,  or 
sometimes  resembled  psoriasis.  The 
disease  was  rebellious  to  treatment, 
and  was  followed,  sooner  or  later, 
after  a  year  or  more,  by  epithelial 
cancer  of  the  mammary  gland.  The 
disease  is  a  true  epithelioma,  not  a 
glandular  cancer.  The  growth  of 
the  epithelial  cells  into  the  deeper 
structures  appears  to  be  due  to 
chronic  irritation,  as  in  epitheli- 
oma of  the  lip  and  elsewhere.  The 
growth  is  not  very  rapid;  the  ax- 
illary glands  are  involved  late  in 
the  disease.  The  diagnosis  is  not 
difficult  after  an  intraglandular  induration  has  formed.  The  disease  occurs 
in  women  between  the  ages  of  forty  and  sixty;  the  course  is  slow. 


Fig.  240. — Epithelioma  of  the  Nipple  (Paget's 
Disease  of  the  Nipple).     (Author's  case.) 


DISEASES    OF   THE   BEEAST 


673 


In  a  case  of  my  own  the  woman  was  aged  forty-five.  There  was  a  his- 
tory of  a  chronic  inflammation  of  the  nipple  and  areola  lasting  for  three  years. 
On  examination  there  was  a  red,  tender,  painful,  moist,  excoriated  area  two 
inches  and  a  half  in  diameter,  including  the  nipple  and  areola,  and  extending 
farther  above  than  below  the  nipple.  The  surface  was  finely  granular  and 
bled  readily;  there  was  no  true  ulceration;  the  borders  of  the  area  were 
sharply  marked  from  the  surrounding  skin.  On  palpation  the  excoriated  area 
was  not  indurated,  but  was  adherent  to  the  deeper  structures.  In  the  sub- 
stance of  the  breast  there  was  a  hard  mass  of  infiltration,  about  two  inches  in 
diameter,  situated,  for  the  most  part,  above  the  nipple.  An  extensive  opera- 
tion was  done.  Diagnosis. — Epi- 
thelioma of  the  mammary  gland. 
Axillary  glands  not  involved.  Pa- 
tient remained  well  at  the  end  of 
five  years. 

Atheromatous  Cysts. — Ather- 
omatous cysts  of  characteristic  ap- 
pearance sometimes  develop  in  the 
areola. 

Pendulous  Tumors  of  the 
Nipple. — Pendulous  tumors  of  the 
nipple  in  the  form  of  adenoma, 
fibroma,  and  angioma  have  been  ob- 
served in  a  few  cases. 

Inflammations  of  the  Breast. — 
— Inflammation  of  the  breast  occa- 
sionally occurs  in  infants  a  few 
days  after  birth ;  the  gland  becomes 
tender  and  swollen;  the  skin  red- 
dened. A  small  quantity  of  clear 
or  milky  fluid  may  be  discharged 
from  the  nipple.  The  process 
usually  subsides  after  a  few  days; 
rarely  suppuration  occurs.     In  boys 

and  girls  at  the  time  of  puberty  an  inflammation  of  the  mammary  gland 
may  occur,  characterized  by  swelling,  induration,  pain,  and  tenderness.  The 
nipple  becomes  red  and  more  prominent;  there  may  be  a  little  milky  dis- 
charge from  the  nipple  and  pigmentation  of  the  areola.  The  process  usu- 
ally ends  in  resolution,  very  rarely  in  suppuration.  The  swelling  and 
tenderness  of  the  breast  during  menstruation  has  already  been  mentioned. 
Hemorrhage  into  the  substance  of  the  breast  has  been  observed  in  cases  of 
irregular  menstruation. 

Acute   Inflammation   of  the  Breast — Acute   Mastitis. — We   distin- 
guish   an    acute    suppurative    mastitis    due    to    infection    with    pus    microbes 
44 


Fig.  241. — Inflammation  of  the  Breast  in  a  Boy; 
no  Apparent  Cause.  (New  York  Hospital  col- 
lection.) 


674  THE   BREAST 

and  an  acute  nonsuppurative  mastitis  due  to  retention  of  milk  in  the  puerperal 
breast.  It  is  to  be  borne  in  mind  that  this  distinction  is  not  always  easy  to 
make  early  in  the  course  of  these  diseases,  because,  although  retention  of  milk 
may  occur  alone,  it  is  also  one  of  the  regular  or  frequent  concomitants  of 
puerperal  abscess  of  the  breast,  and  renders  the  local  conditions  favorable  for 
infection.  Acute  suppurative  mastitis  may  occur  from  infected  wounds,  from 
furuncles,  or  small  abscesses  of  the  skin  of  the  breast  or  areola,  or  as  a  metas- 
tatic process  in  pyemia.  In  the  largest  proportion  of  cases  it  follows  child- 
birth during  the  nursing  period,  most  often  during  the  first  four  weeks  after 
labor.  The  infection  takes  place  through  abrasions,  fissures,  or  excoriations 
of  the  nipple  or  areola,  and  follows  the  lymphatic  channels  into  the  substance 
of  the  gland,  or  through  the  orifices  of  the  milk-ducts,  the  bacteria  multiplying 
in  the  milk,  and  thence  infecting  the  surrounding  structures.  The  ordinary 
pus-producing  organisms — staphylococcus,  streptococcus,  colon  bacillus,  and 
in  a  few  eases  the  gonococcus— have  been  identified  in  the  milk  or  in  the  pus. 
The  suppurative  process  is  usually  circumscribed,  involving  a  certain  limited 
area  of  gland  tissue,  more  commonly  situated  in  the  lower,  or  lower  and  outer, 
quadrant  of  the  breast.  In  other  cases  it  is  diffuse;  the  entire  gland  is  rid- 
dled with  pus  foci.  In  still  others  a  retromammary  abscess  may  exist  alone, 
between  the  breast  and  the  pectoral  muscle,  or  may  be  formed  by  extension  of 
the  infection  of  the  gland  itself.  Occasionally  an  abscess  forms  in  front  of 
the  gland,  in  the  areola,  or  in  the  skin ;  the  superficial  situation  makes  the 
diagnosis  simple. 

Symptoms. — The  symptoms  and  signs  of  acute  suppurative  mastitis,  as  it 
ordinarily  occurs  after  labor,  are  pain,  referred  to  the  breast,  greatly  increased 
by  allowing  the  child  to  nurse.  As  the  disease  progresses  nursing  becomes 
unbearable.  Fever,  usually  high  and  of  a  septic  type,  not  infrequently  ushered 
in  by  a  chill.  Leucocytosis  in  varying  degree,  with  a  high  percentage  of  large 
polynuclear  cells,  is  regularly  present.  On  palpation  a  greater  or  less  area 
of  the  breast  is  found  hard,  infiltrated,  and  tender.  As  the  focus  approaches 
the  surface  the  skin  becomes  edematous  and  reddened.  A  doughy,  soft,  or 
elastic  area  indicates  the  formation  of  an  abscess.  Bacteriological  examination 
of  the  milk  is  sometimes  a  useful  aid  in  diagnosis,  notably  in  those  cases  caused 
by  infection  through  the  milk-ducts  and  not  accompanied  by  fissures  and  ex- 
coriations of  the  nipple.  Owing  to  the  pain,  nursing  is  impossible,  and  unless 
artificial  means  are  used  to  empty  the  breast — and  this  may  not  be  practicable, 
owing  to  tenderness  or  inflammatory  swelling  of  the  ducts — the  entire  breast  is 
swollen,  tense,  and  distended  with  retained  secretion.  The  occurrence  of  abscess 
is  popularly  attributed  to  retention  of  the  milk,  and  doubtless  such  retention 
renders  the  breast  more  susceptible  to  infection,  but  in  the  majority  of  in- 
stances the  infection  precedes  and  causes  the  retention.  In  many  cases  of 
mammary  abscess  superficial  lymphangitis,  with  red,  tender  lines  upon  the 
skin  running  to  the  axilla,  and  tenderness  and  enlargement  of  the  axillary 
lymph  nodes,  gives  early  evidence  of  the  infectious  nature  of  the  condition. 


DISEASES    OF    THE    BREAST 


675 


Under  neglect,  or  imperfect  operative  treatment,  the  infection  may  spread 
through  a  large  part  of  or  through  the  entire  gland,  so  that  the  whole  breast  is 

riddled  with  purulent  foci;  further  extension  may  occur,  and  a  large  purulent 
collection  form  beneath  the  breast,  lifting  the  gland  from  the  thorax.  In  these 
cases  the  local  signs  and  constitutional  symptoms  become  correspondingly  serious 
and  severe.  The  attack  is  sometimes  grave.  In  several  cases  I  have  seen,  as 
the  result  of  no  treatment,  or  of  imperfect  operation,  fatal  pyemia  has  occurred ; 
in  others,  entire  destruction  of  the  breast,  "with  recovery  after  amputation  of 
the  breast ;  in  others,  tedious  healing  with  persistent  sinuses,  the  formation  of 
massive  ugly  scars  and  destruction  of  the  gland.  Persistent  sinuses  may 
remain,  from  which  milk  and  pus  are  discharged.  It  rarely  happens  from 
occlusion  of  one  or  more  ducts  that  a  true  milk-cyst  of  considerable  size 
is  produced  (galactoeele).  The  presence  of  a  cystic  tumor  yielding  milk, 
or  buttery,  oily  material 
cm  aspiration  establishes 
the  diagnosis. 

Diagnosis. — In  the  di- 
agnosis of  purulent  infec- 
tion of  the  breast  several 
practical  points  should  be 
borne  in  mind.  Superfi- 
cial abscess  in  front  of  the 
breast  is  attended  by  all 
the  signs  of  acute  abscess, 
and  is  easily  recognized. 
Deep-seated  foci  in  the  sub- 
stance of  the  gland  give  the 
local  signs  of  one  or  more 
tender,  painful,  indurated 
areas  in  the  gland  and  the 
general  symptoms  of  sepsis. 
The  pain  of  intramammary 
abscess  is  intense,  sharp, 
and  lancinating.  That  ac- 
companying retromammary 
abscess  is  continuous,  dull, 
and  throbbing.  In  these 
cases  the  whole  breast  will 
feel  hot  to  the  examining 
hand,  but  localized  red- 
ness and  a  sense  of  fluctuation  may  be  absent,  and  the  surgeon  who  waits 
for  these  signs  before  affording  operative  relief  subjects  his  patient  to  an 
unnecessary  amount  of  pain  and  danger.  Retention  of  pus  in  the  wound, 
continuance  of  pain,  fever,  prostration,  and  leucocytosis  usually  indicates  that 


Fig.  242. — Acute  Inflammation  of  the  Breast  in  a  Nurs- 
ing Woman  Followed  by  Abscess.  (Author's  collec- 
tion.) 


676  THE   BREAST 

the  operative  procedures  have  been  inadequate.  Retromammary  abscess  is  to 
be  recognized  by  marked  projection  of  the  entire  gland  from  the  chest  wall 
and  severe  constitutional  symptoms.  On  palpation  the  gland  itself  may  feel 
normal;  lateral  compression  may  not  be  painful;  pressure  directed  backward 
causes  pain;  fluctuation,  when  present,  is  usually  felt  above  the  superior  bor- 
der of  the  gland.  If  the  breast  is  lifted  so  that  the  pus  sinks  down  behind  the 
gland  the  sense  of  fluctuation  may  be  lost.  If  the  amount  of  pus  is  large  the 
gland  may  be  lifted  off  the  thorax,  and  a  sense  of  fluctuation  may  be  obtained 
on  pushing  the  entire  breast  backward  against  the  thoracic  wall.  The  aspirat- 
ing needle  may  be  used  in  any  case  to  detect  the  presence  of  pus. 

Acute  Nonsuppurative  Mastitis  —  Retention  of  Milk  —  Caked 
Breast. — This  condition  as  a  separate  entity  apart  from  an  infectious  lesion 
of  the  breast  is  not  rare.  It  may  occur  during  the  latter  days  of  preg- 
nancy, but  is  more  common  during  the  days  following  labor;  less  common 
during  the  later  period  of  lactation.  The  retention  is  usually  confined  to  a 
limited  area,  or  areas,  of  the  gland.  The  affected  lobules  become  tender,  pain- 
ful, and  swollen.  There  may  be  a  little  fever,  the  entire  breast  is  enlarged 
and  engorged  with  blood.  Artificial  removal  of  the  milk  causes  the  symptoms 
to  subside.  Absence  of  the  local  signs  of  abscess,  of  intense  pain,  etc.,  and  of 
leucocytosis ;  a  sterile  condition  of  the  milk  and  absence  of  the  septic  symp- 
toms aid  in  the  diagnosis. 

Chronic  Abscesses  of  the  Breast. — In  a  certain  number  of  cases,  usu- 
ally connected  with  lactation,  a  circumscribed  portion  of  the  breast  becomes 
tender,  hard,  and  painful,  but  the  process  stops  short  of  invasion  of  the  skin, 
softening  and  perforation.  The  symptoms  subside,  and  the  gland  returns  to  a 
normal  condition,  or  in  other  cases  a  permanent  nodular  thickening  is  left 
behind.  In  still  other  cases  the  acute  symptoms  subside;  the  nodule  remains 
and  is  the  seat  of  some  dull  pain  and  discomfort,  or  causes  anxiety  merely 
on  account  of  its  presence.  Examination  of  such  a  nodule  shows  that  the 
lump  is  firm  or  elastic  and  a  little  tender.  If  deeply  embedded  in  the  breast, 
it  may  give  the  impression  of  a  solid  tumor.  Exploration  with  a  needle,  or 
incision,  shows  a  cystlike  cavity  filled  with  pus  and  surrounded  by  a  limiting 
wall  of  dense  fibrous  tissue.  Such  pus  may,  or  may  not,  contain  living  pus 
germs.  I  have  removed  such  abscesses  which  had  existed  for  several  years. 
Excision,  not  incision,  is  the  proper  treatment. 

Chronic  Mastitis. — Chronic  interstitial  mastitis  with  atrophy  of  the 
gland  tissue  and  the  production  of  dense  contracting  masses  and  nodules  of 
fibrous  tissue  in  the  breast  occurs  usually  near  the  menopause.  The  disease 
is  of  slow  progress,  and  is  attended  by  moderate  pain  and  discomfort;  the 
gland  is  diminished  in  size;  nodular  masses  and  cords  of  dense  fibrous  tissue 
are  palpable  in  the  breast,  sometimes  extending  toward  the  axilla.  In  some 
cases  the  nipple  may  be  retracted ;  the  gland  remains  movable,  the  axillary 
glands  are  not  enlarged.  Many  of  these  cases  end  in  carcinoma ;  nor  is  a 
differential    diagnosis    possible    without    a    careful    microscopic    examination 


DISEASES    OF   THE   BBEAST  677 

of  sections  of  the  indurated  tissue.  Solitary  or  multiple  cystic  dilata- 
tions of  the  milk-ducts  may  occur  in  these  cases  from  obstruction  of  the 
ducts  and  retention  of  their  secretion ;  such  cysts  may  attain  the  size  of  a 
hen's  egg. 

Chronic  Cystic  Mastitis  {Cystadenoma  mamma?) . — The  exact  pathol- 
ogy of  this  disease  is  variously  explained  by  different  observers.  By  some  it 
is  regarded  as  distinctly  an  inflammatory  process ;  by  others  rather  as  a  new 
growth  than  as  an  inflammation.     (Schimmelbusch)  Cystadenoma  mammae. 

Schimmelbusch  describes  the  lesion  as  follows : 

The  primary  changes  are  not  a  dilatation  or  closure  of  the  glandular  ducts, 
but  a  proliferation  of  the  epithelia  of  the  acini,  without  any  evidence  of  increase 
in  the  number  of  nuclei,  or  cellular  infiltration  of  the  connective  tissue.  The  acini 
are  entirely  filled  and  dilated  by  the  epithelial  growth.  By  the  subsequent  degen- 
eration of  this  epithelium  a  cavity  or  cyst  is  formed. 

Sasse  considers  that  the  formation  of  cysts  may  occur  in  two  ways :  by  mul- 
tiplication of  epithelium,  as  described  by  Schimmelbusch;  and  by  an  interstitial 
mastitis  with  pressure  upon  and  dilatation  of  the  glandular  ducts.  (For  other 
views  the  reader  is  referred  to  special  works  on  surgical  pathology  and  to 
monographs  by  W.  Mintz,  Koloff,  and  Tietze.) 

Clinical  Characters. — The  disease  is  characterized  by  the  formation  of 
smaller  or  larger  cystic  cavities  in  the  breast,  containing  clear,  colorless,  or 
greenish-brown  fluid,  and  by  dilatation  of  the  milk-ducts.  The  fibrous  stroma 
of  the  breast  is  swollen  and  infiltrated  with  round  cells.  The  cavities  vary  in 
size  from  the  head  of  a  pin  to  that  of  a  pigeon's  egg,  and  in  fully  developed 
cases  are  scattered  everywhere  throughout  the  substance  of  the  gland.  The 
disease  is  frequently  bilateral.  It  may  develop  at  any  time  after  puberty, 
and  appears  to  be  more  common  among  Avomen  who  have  borne  children,  but 
have  not  nursed  them.  There  is  commonly  a  history  of  a  painful  swelling 
of  one  or  both  breasts  during  menstruation;  afterwards  the  pain  and  swelling 
may  subside,  but  one  or  more  tender  nodules  remain  behind ;  this  process  is 
repeated  from  time  to  time.  According  to  Konig,  the  following  is  a  typical 
picture  of  the  condition: 

On  palpation  with  the  finger  tips  the  disseminated  nodules  can  be  distinctly 
felt,  notably  if  a  portion  of  the  breast  is  lifted  away  from  the  chest  between  the 
finger  and  thumb.  Upon  pressing  the  breast  against  the  thorax  with  the  palm  of 
the  hand  no  nodules  are  distinguished,  and  it  is  sometimes  necessary  to  grasp  the 
breast  in  some  particular  direction  in  order  that  they  may  be  felt.  The  nodules 
are  smooth,  tense,  or  elastic,  sometimes  distinctly  fluctuating,  and  are  seldom  as 
large  as'  a  pigeon's  egg. 

In  my  own  experience  they  often  feel  the  size  and  shape  of  buckshot  and 
quite  hard.  Pressure  upon  the  nodules  sometimes  causes  the  escape  of  clear, 
milky,  or  brown-colored  fluid  from  the  nipple.     The  skin  does  not  become 


678  THE    BEEAST 

adherent  to  the  gland,  nor  the  gland  to  the  underlying  muscle  and  fascia.  The 
axillary  glands  are  not  enlarged.  These  characters,  together  with  the  increased 
pain  and  swelling  during  menstruation,  the  slowly  progressive  manner  in 
which  the  disease  gradually  occupies  the  entire  gland,  the  fact  that  both  breasts 
are  often  involved,  and  the  characteristic  multiple  nodules  in  the  breast,  render 
the  diagnosis  clear  in  well-marked  cases. 

In  some  cases  proliferation  of  the  epithelium  lining  the  cyst  walls  may 
occur  with  the  formation  of  considerable  tumors,  and  increase  in  the  pain  and 
discomfort.  Cancerous  degeneration  is  not  infrequent.  Operative  removal  of 
the  entire  gland  is  desirable  when  the  patient  is  over  thirty-five  years  of  age, 
when  much  pain  and  discomfort  are  present,  and  in  cases  where  the  mind  of 
the  patient  dwells  upon  the  condition  of  the  breasts.  Opinions  differ  among 
surgeons  as  to  the  radical  treatment  of  milder  cases.  Personally,  I  believe  the 
condition  a  threatening  one,  which  justifies  removing  the  breast.  I  have  sev- 
eral times  found  beginning  cancerous  changes  in  cases  believed  to  be  quite 
innocent.  There  are  also  combinations  of  cystic  mastitis  and  the  chronic  inter- 
stitial sclerosis  of  the  breast  (chronic  interstitial  mastitis).  In  these  cases 
one  or  more  cystlike  cavities  exist  in  the  dense  fibrous  stroma  of  the  atrophic 
breast. 

Tuberculosis  of  the  Mamma. — Primary  tuberculosis  of  the  mamma  is  a 
rare  disease.  The  infection  may  occur  through  the  blood  or,  apparently,  through 
the  milk-ducts.  Tuberculosis  of  the  breast  as  an  extension  from  tuberculous 
caries  of  the  ribs,  sternum,  or  pleura  is  not  uncommon.  Primary  tuberculosis 
of  the  breast  is  more  frequent  in  women  than  in  men.  It  does  not  occur  before 
puberty  and  very  rarely  in  old  age.  Associated  tuberculous  lesions  are  com- 
mon; the  axillary  glands  are  often  involved.  The  disease  may  occur  as  an 
isolated  lesion  with  the  production  of  a  solitary  cold  abscess,  or  as  a  dissemi- 
nated process  with  multiple  foci,  which  undergo  degeneration  with  the  forma- 
tion of  multiple  tuberculous  abscesses  and  fistula?.  Further,  as  a  diffuse 
submiliary  tuberculosis  of  the  entire  gland,  including  the  nipple. 

The  diagnosis  of  tuberculosis  of  the  breast  is  easy  if  tuberculous  sinuses  or 
ulcers  are  present,  the  appearances  being  quite  typical.  In  other  cases  the 
diagnosis  will  rarely  be  made  without  operation.  In  the  case  of  a  solitary  cold 
abscess  there  will  be  the  history  of  a  slowly  growing  tumor  in  the  gland ;  little 
or  no  pain  or  tenderness ;  a  tense  and  elastic  or  fluctuating  nodule  will  be  felt 
in  the  breast,  rarely  surrounded  by  a  dense  layer  of  infiltrated  tissue.  Incision 
permits  the  escape  of  typical  tuberculous  pus  and  cheesy  material;  the  cavity 
is  lined  by  typical  tuberculous  granulation  tissue.  In  the  disseminated  and 
diffuse  form  numerous  nodular  masses  will  be  felt  in  the  breast,  of  varying 
size  and  consistence.  The  nipple  may  be  retracted,  but  the  breast  is  movable 
on  the  pectoral  muscle,  or,  more  rarely,  adherent.  The  axillary  glands  are 
often  enlarged  and  hard  or  broken  down  and  fluctuating.  The  condition  is 
evident  on  incision  in  many  cases ;  in  others  the  diagnosis  has  only  been  made 
after  microscopical  examination  of  the  diseased  tissues.     Both  the  solitary  and 


DISEASES    OF   THE   BKEAST  679 

disseminated  forms  are  characterized  by  ;m  extremely  chronic  course;  the  nod- 
ules may  exist  for  years  without  invasion  of  the  skin.  In  some  cases  the 
disease  makes  more  rapid  progress;  the  nodules  become  confluent;  abscesses  and 
sinuses  form.  The  axillary  glands  are  involved  in  a  large  proportion  of  cases, 
and  the  process  in  the  glands  is  apt  to  he  more  rapid,  so  that  the  focus  in  the 
breast,  being  painless,  might  not  attract  attention.  In  some  cases  a  palpable 
cord  of  infected  tissue  has  been  noted  passing  from  the  breast  to  the  axillary 
glands. 

Diffuse  Miliary  Tuberculosis  of  tiie  Breast. — Diffuse  miliary  tuber- 
culosis of  the  breast  is  a  rare  lesion.  The  following  case  from  my  own  experi- 
ence is  perhaps  worthy  of  record : 

The  patient  was  a  large,  well-nourished  woman,  forty-two  years  old,  the 
mother  of  several  healthy  children.  There  was  no  tubercular  history  in  her 
own  life.  For  several  years  she  had  noticed  a  lump  in  the  left  breast,  which 
had  slowly  increased  in  size,  giving  no  symptoms  other  than  those  due  to  its 
mechanical  presence,  a  sense  of  weight  and  fullness  in  the  breast,  and  a  little 
dull  pain  from  time  to  time.  Two  months  before  I  saw  her  the  breast  had 
commenced  to  grow  larger  quite  rapidly.  It  had  become  tender  and  some- 
what painful;  these  symptoms  were  steadily  getting  worse.  On  examination 
the  breast  was  notably  and  symmetrically  enlarged ;  the  skin  over  the  entire 
breast  was  slightly  reddened  and  edematous,  and  immovable  over  the  gland; 
the  nipple  was  swollen  and  unduly  prominent.  On  palpation  the  breast  was 
occupied  by  a  hard,  dense  tumor ;  the  general  outline  of  the  tumor  was  rounded, 
and  appeared  to  be  covered  by  a  layer  of  inflamed  and  infiltrated  skin  and 
glandular  tissue.  The  tumor  was  movable  upon  the  pectoral  muscle;  the  axil- 
lary glands  were  enlarged,  a  little  tender,  and  soft,  rather  than  hard.  The 
patient  had  a  slight  rise  of  temperature  every  evening. 

The  diagnosis  was  made  of  a  benign  tumor  which  had  undergone  a  malig- 
nant degeneration,  of  a  character  not  entirely  clear.  A  large  portion  of  skin, 
the  breast,  the  pectoral  muscles,  and  axillary  contents  were  removed  in  one 
piece.  The  patient  made  a  complete  recovery  and  continued  in  good  health. 
Pathological  examination  showed  the  tumor  of  the  breast  to  be  a  fibro-adenoma. 
The  nipple,  the  areola,  the  skin  and  subcutaneous  tissues  overlying  the  breast, 
the  gland  itself  throughout,  was  the  seat  of  an  acute  submiliary  and  miliary 
tuberculosis.  None  of  the  tubercles  was  larger  than  a  No.  10  shot.  The  axil- 
lary glands  were  the  seat  of  an  early  acute  tuberculosis;  there  was  no  evi- 
dence to  show  that  they  had  been  primarily  infected. 

Actinomycosis  of  the  Breast. — Actinomycosis  of  the  breast  is  an  ex- 
tremely rare  localization.  The  disease  presents  itself  in  the  guise  of  a  sub- 
acute inflammation  of  the  breast  with  formation  of  hard  nodules,  .which  later 
form  abscesses.  The  characteristic  granules  establish  the  diagnosis.  The  ribs 
and  pleura  may  be  involved,  and  dissemination  of  the  disease  is  not  improb- 
able. The  method  of  inoculation  in  the  recorded  cases  could  not  be  demon- 
strated. 


680  THE   BREAST 

Gummata  of  the  Mamma. — The  diagnosis  of  gumma  of  the  breast  is  easy 
in  the  presence  of  a  crateriform  ulcer  lined  with  gummy  material.  In  other 
instances  the  presence  of  a  hard  or  elastic  painless  nodule  in  the  breast,  of 
slow  or  moderately  rapid  growth,  which  came  to  be  fluctuating  without  notable 
increase  in  size,  and  without  any  of  the  concomitants  of  malignant  disease, 
might  lead  to  the  use  of  iodid  internally ;  improvement  or  cure  of  the  tumor 
would  establish  the  diagnosis.  Upon  incision,  the  absence  of  cheesy  pus  and 
of  a  lining  membrane  of  tubercle  tissue,  together  with  the  typical  appearance 
of  gummy  material,  would  usually  prevent  error.  A  diffuse  syphilitic  mastitis 
has  been  described.  Here,  as  elsewhere,  the  history  and  other  evidences  of 
syphilitic  infection  are  important. 

Neuralgia  of  the  Breast. — Mastodynia  occurs  chiefly  in  neurotic  and  hys- 
terical females,  and  in  those  subject  to  intercostal  neuralgias.  Fear  of  malig- 
nant disease  is  often  present;  the  breast  is  usually  normal  in  appearance. 
Shooting  pains  are  complained  of  in  the  breast,  the  side,  the  inner  surface 
of  the  arm,  and  the  shoulder.  Physical  examination  shows  extreme  sensitive- 
ness on  palpation,  often  hyperesthesia  of  the  skin;  the  breast  may  appear  a 
little  enlarged;  a  mastitis  of  one  or  more  lobules,  or  a  neurofibroma,  may  be 
palpable,  or  nothing  may  be  found.  The  pain  and  hyperesthesia  are  usually 
worse  during  menstruation.     Uterine  and  adnexal  disease  should  be  excluded. 

Hypertrophy  of  the  Breast. — Great  enlargement  of  the  breast  may  be  a  true 
hypertrophy  of  all  the  structures,  including  the  gland  tissue.  Such  unusually 
large  breasts  may  occur  in  virgins,  but  are  more  common  during  pregnancy. 
After  lactation  is  over  they  may  greatly  diminish  in  size.  These  breasts  do  not 
grow  to  enormous  proportions,  and  do  not  necessitate  surgical  operations.  The 
occurrence  of  such  hypertrophies  is  most  unusual.  Another  variety,  more  com- 
mon, but  still  exceedingly  rare,  is  a  diffuse  fibro-lipoma  of  the  breast,  in  which 
either  the  fat  or  the  fibrous  tissue  may  predominate ;  scattered  glandular  tubules 
and  imperfectly  developed  acini  are  found  in  the  growth.  In  these  cases  the 
true  glandular  substance  undergoes  atrophy;  in  some  cases  cysts  are  formed. 
Usually  both  breasts  are  involved,  first  one,  then  the  other ;  in  a  few  cases 
but  one  breast  becomes  enlarged.  The  growth  occurs  in  young  women  and 
girls  either  at  puberty  or  later,  often  during  pregnancy.  The  increase  takes 
place  rapidly,  and  may  reach  a  large  size  in  a  few  months.  It  is  said  that  the 
growth  is  always  intermittent.  Successive  accessions  in  size,  following  at 
irregular  intervals,  or  as  the  result  of  pregnancy. 

At  first  the  growing  breast  is  firm  and  prominent,  soon  it  becomes  flaccid 
and  pendent;  the  skin  remains  normal,  but  may  become  edematous;  dilated 
subcutaneous  veins  are  apparent ;  the  areola  is  increased  in  size,  the  nipple 
flattened.  The  breasts  may  reach  to  the  pubes,  or  lower,  and  each  breast  may 
weigh  many  pounds;  breasts  of  twenty  to  thirty  and  forty  pounds  have  been 
recorded.  The  patients  suffer  much  discomfort  from  the  enormous  size  of  the 
breasts ;  they  may  be  unable  to  walk ;  the  breasts  require  some  artificial  sup- 
port, such  as  a  table,  to  enable  the  patient  to  sit  up.     They  become  anemic  and 


TUMORS    OF    THE    BREAST 


681 


may  suffer  from  dyspnea.  Slight  traumatisms  may  cause  ulceration  and  slough- 
ing of  the  breasts ;  erysipelas  has  destroyed  life  in  several  cases.  In  the  event 
of  pregnancy,  the  increase  may  be  very  rapid  and  attended  by  much  pain, 
and  even  alarming  symptoms  of  exhaustion,  due  to  the  failure  of  general 
nutrition. 

TUMORS   OF   THE   BREAST 

General  Considerations  and  Statistics. — Tumors  of  the  breast  occur  with 
great  frequency  in  the  female;  less  commonly  in  the  male.  In  the  female 
breast  almost  every  variety  of  benign  and  malignant  growth  has  been  observed. 
The  malignant  growths  constitute  nearly  ninety  per  cent  of  all  tumors  of  the 
breast ;  of  these,  eighty  per  cent  are  carcinomata ;  the  sarcomata  vary  in  the 
statistics  of  different  clinics  between  six  per  cent  and  nine  per  cent,  leaving 
a  little  more  than  ten  per  cent  only  of  benign  growths.  Among  the  benign 
growths,  the  fibro-adenomata  are  much  the  most  frequent.  Pure  fibroma  and 
pure  adenoma  are  surgical  rarities  in  this  locality. 

Benign  Tumors  of  the  Breast. — Fibro-adenoma. — These  tumors  present 
themselves  in  a  variety  of  forms,  according  to  the  relative  growth  and  to  the 
arrangement  of  the  fibrous  stroma  and  of  the  glandular  substance  respectively. 
In  some  cases  the  dense  fibrous  stroma  is  greatly  in  excess,  in  others  the  glan- 
dular substance ;  in  consequence,  the  growths  are  harder  or  softer,  as  the  case 
may  be.  The  following  description  of  the  varieties  of  fibro-adenoma  of  the 
breast  is  adapted  from  Schimmelbusch :  In  some  cases  the  glandular  tubules 
increase  in  length  and  breadth,  as 
do  the  acini,  but  remain  flat  and 
narrow,  with  the  production  of  slit- 
like cavities  in  the  tumor  lined 
with  cylindrical  epithelium.  This 
mode  of  growth  may  give  the  tumor 
the  appearance  of  being  made  up 
of  thin  layers  of  fibrous  tissue  sepa- 
rated by  narrow  clefts.  The  for- 
mation and  retention  of  a  mucoid 
secretion  in  the  alveoli  may  lead 
to  the  formation  of  cysts  (cysto- 
adenoma).  An  irregular  growth 
of  the  fibrous  stroma  may  cause 
projections  and  polypoid  or  flat 
excrescences  in  the  dilated  acini 
(intracanalicular  fibroma,  cystosar- 
coma  proliferum).  Myxomatous 
degeneration  of  the  stroma  renders 

the  tumor  softer;  this  condition  may  be  combined  with  proliferation  of  the 
glandular  epithelium  or  with  the  cyst  formation  (cystosarcoma  phyllodes,  in- 


Fig.  243. — Fibro-adenoma  of  the  Breast  in  a 
Young  Girl,  Aged  Fourteen.  (Author's  col- 
lection.) 


682 


THE   BREAST 


tracanalicular  myxoma).  These  distinctions  are  rather  of  interest  to  the 
pathologist  than  to  the  surgeon,  and  are  not  of  great  clinical  importance, 
except  that  they  cause  the  tumor  to  he  hard  or  soft,  or  to  vary  in  consistence 
in  different  portions  of  the  same  growth. 

Clinically,  upon  section,  the  fibro-adenomata  are  grayish-white  in  color,  of 
homogeneous  texture,  except  when  cysts  are  present.     They  are  often  distinctly 

lobulated;  the  fibrous  layers  are 
sometimes  arranged  concentrically 
like  the  several  layers  of  an  onion. 
The  consistence  is  more  or  less  firm, 
according  to  the  greater  or  less  de- 
velopment of  fibrous  stroma  or  of 
glandular  elements.  Myxomatous 
degeneration  causes  the  tumor  to 
become  notably  soft,  sometimes  al- 
most semifluid.  The  growth  is  sur- 
rounded by  a  distinct  fibrous  cap- 
sule. The  fibro-adenomata  occur 
for  the  most  part  in  young  women, 
rarely  after  the  fortieth  year  of 
life.  They  are  painless,  distinctly 
movable  in  the  breast,  from  which 
they  may  even  appear  to  be  de- 
tached ;  they  do  not  become  adher- 
ent to  the  skin  nor  ulcerate ;  the 
axillary  glands  are  not  enlarged. 
The  tumors  vary  in  size  from  a 
walnut  to  that  of  a  child's  head, 
such  large  tumors  being  rare.  They 
usually  grow  quite  slowly ;  they  are  smooth,  rounded,  or  lobulated  in  contour, 
usually  firm,  although  harder  and  softer  places  may  alternate  in  the  same 
growth  after  the  tumor  has  grown  to  considerable  size  and  has  undergone 
mucous  or  cystic  degeneration.  Large  tumors  may  give  rise  to  disagreeable 
symptoms  by  weight  and  pressure.  Rarely  the  circulation  of  the  tumor  may 
be  imperfect,  so  that  necrosis  of  the  entire  tumor  takes  place;  infection  and 
abscess  of  the  breast  is  the  usual  cause  of  this  event. 

It  is  to  be  borne  in  mind  that  the  fibro-adenomata  of  the  breast,  notably 
those  in  which  the  epithelial  elements  predominate,  may,  after  having  existed 
for  years,  undergo  carcinomatous  degeneration.  The  early  removal  of  these 
tumors  is,  therefore,  indicated  in  every  instance. 

Cystosarcoma  of  the  Breast  (Cystosarcoma  phyllodes,  Cystosar- 
coma  pbomferum). — It  is  customary  to  distinguish  under  one  of  the  above 
titles  a  not  very  uncommon  tumor  of  the  female  breast  having  peculiar  clinical 
features,  differing  from  ordinary  fibro-adenoma  of  the  breast  on  the  one  hand, 


Fig.  244. — Fibro-adenoma  of  the  Breast  of  Large 
Size.     (Collection  of  Dr.  F.  W.  Murray.) 


TUMORS    OF   THE   BKEAST  683 

and  from  typical  solid  sarcoma  on  the  other.  The  true  pathological  position 
of  this  growth  is  perhaps  not  definitely  fixed.  Under  the  name  cystosarcoma 
phyllodes  it  was  first  described  by  Johannes  Miiller.  The  tumor  is  really  one 
of  the  varieties  of  fibro-adenoma,  characterized,  however,  by  a  tendency  to 
undergo  sarcomatous  degeneration. 

The  tumors  occur  a  little  later  in  life  than  do  the  ordinary  fibro-adenomata. 
In  thirty-five  cases  collected  by  Gross  the  average  age  was  33.7  years.  In 
their  early  stages  they  are  not  to  be  differentiated  clinically  from  ordinary 
fibro-adenoma,  and  may  remain  small  for  a  long  period  and  suddenly  take  on 
a  rapid  growth.  They  often  attain  a  considerable  size,  so  that  the  entire 
breast  is  occupied  by  the  growth  and  forms  a  large  pendent  mass.  The  tumor 
retains  a  connective-tissue  capsule  throughout,  and  while  small  is  freely  mov- 
able. Lymphatic  infection,  metastasis,  and  cachexia  do  not  occur.  The  skin 
is  very  rarely  involved,  but  may,  very  late  in  the  disease,  become  adherent, 
edematous,  and  even  ulcerated.  The  subcutaneous  veins  may  be  dilated,  the 
tumor  is  of  uneven  surface,  and  often  covered  by  rounded  cystic  knobs ;  in 
other  places  hard  areas  are  present.  There  may  be  a  mucoid  or  serous  dis- 
charge from  the  nipple.  These  tumors  never  become  adherent  to  the  pectoral 
fascia  or  muscles.  Only  in  rare  cases  is  the  nipple  retracted.  On  gross  exami- 
nation the  tumor  is  white  or  reddish  in  color,  and  of  uneven  consistence,  firm 
and  soft  or  fluctuating  areas  are  present  here  and  there.  Section  of  the  tumor 
shows  irregular  cystlike  cavities  containing  mucoid,  rarely  blood-stained  fluid, 
occasionally  pearl-like  masses  of  epithelium.  Papillary  outgrowths  and  flat 
projections,  covered  by  layers  of  proliferating  cylindrical  epithelial  cells,  pro- 
ject into  the  cavities,  and  partly  fill  them.  The  stroma  in  spots  is  in  a  state 
of  mucous  degeneration  or  is  edematous,  in  other  places  fairly  firm,  but  densely 
infiltrated  with  round  cells ;  areas  of  spindle  cells  may  also  be  seen.  True 
sarcomatous  degeneration  may,  as  stated,  occur. 

Pure  myxoma  of  the  breast,  except  as  the  result  of  mucous  degeneration 
of  a  fibro-adenoma,  is  exceedingly  rare.  Clinically  the  two  cannot  be  differen- 
tiated. Lipoma  of  the  breast  is  nearly  always  a  retromammary  tumor  which 
pushes  the  gland  prominently  forward.  The  slow  growth  and  elastic  character 
of  the  growth  render  the  diagnosis  not  difficult.  Chondroma  is  a  very  rare 
tumor  of  the  breast,  and  the  same  is  true  of  osteoma.  Such  tissues  may  occur 
in  mixed  tumors  of  the  gland,  usually  sarcomata,  sometimes  in  carcinomata. 
Typical  atheromatous  cysts  and  cholesteatomata  of  the  breast  have  been  ob- 
served in  a  few  cases.  The  cysts  are  of  slow,  painless  growth,  form  smooth 
elastic  rounded  swellings  containing  characteristic  contents. 

Malignant  Tumors  of  the  Breast. — Sarcoma  of  the  Breast. — All  the  forms 
of  true  sarcoma  may  occur  in  the  breast.  (See  Sarcoma.)  As  stated,  they  are 
far  less  frequent  than  carcinomata.  Here,  as  elsewhere,  the  soft,  rapidly  grow- 
ing, round-celled,  medullary,  and  melanotic  sarcomata  are  the  most  malignant, 
the  latter  being  fortunately  rare.  The  spindle-celled  firm  tumors  are  less 
malignant.     Sarcoma  of  the  breast  may  occur  at  any  age.     The  spindle-celled 


684 


THE   BREAST 


and  so-called  cystosarcoma  are  rather  more  frequent  during  the  period  of  func- 
tional activity  of  the  breast.     The  more  malignant  forms  more  commonly  occur 

during  or  after  the  meno- 
pause. In  their  early  stages 
it  is  quite  impossible  by  ex- 
ternal palpation  to  distin- 
guish the  sarcomata  from 
other  forms  of  tumor  in  the 
breast.  They  form  nodular 
masses,  usually  solitary, 
often  encapsulated,  and  at 
first  movable.  Of  any  pos- 
sible degree  of  hardness  or 
softness.  The  harder  forms 
may  be  mistaken  for  fibro- 
adenoma, if  movable ;  for 
carcinoma,  if  attached;  for 
cystic  tumors,  if  very  soft. 
As  they  increase  in  size  the 
distinctive  characters  of  sar- 
coma become  more  marked. 
They  are  painless  tumors. 
The  more  benign  forms  grow 
slowly  and  are  hard;  the 
more  malignant  rapidly,  and 
soon  become  soft.  They  sooner  or  later  infiltrate  and  become  adherent  to  sur- 
rounding structures.  They  rarely  ulcerate  until  late  in  the  disease.  The  softer 
forms  are  often  very  vascular  tu- 
mors and  may  pulsate ;  dilated  veins 
are  to  be  noted  on  the  surface.  The 
axillary  glands  are  secondarily  in- 
volved only  in  rare  cases  and  late. 
There  may  be  a  serous  or  bloody 
discharge  from  the  nipple.  Dis- 
semination takes  place  rather  by  the 
blood  current ;  and  secondary  growths 
in  the  lung,  liver,  bones,  brain,  and 
elsewhere  are  common.  Cachexia  is 
present  in  the  late  stages.  The  clin- 
ical signs  and  symptoms  are,  as  will 
be  seen,  quite  different  in  well-de- 
veloped cases  from  carcinoma. 

Carcinoma  of  the  Breast. — As  already  stated,  about  eighty  per  cent  of 
all  tumors  of  the  breast  are  carcinomata.     They  occur  in  all  countries  and 


Fig.  245. — Ulcerated  Sarcoma  of  the  Breast 
of  Dr.  Charles  McBurney.) 


(Collection 


Fig.  246. 


-Ulcerating  and  Fungating  Sarcoma 
of  the  Breast;  Inoperable. 


TUMORS    OF   THE    BREAST  685 

among  all  peoples,  but  are  said  to  lie  more  frequent  among  the  white  than 
the  dark-skinned  races  of  mankind.  There  seems  to  be  no  doubt  but  that  the 
number  of  recorded  deaths  from  cancer  has  steadily  increased  during  the  past 
fifty  years.  The  increase  appears  to  keep  pace  to  some  extent  with  the  material 
prosperity  of  a  community,  and  the  theory  has  been  advanced  that  more  lux- 
urious living,  and  especially  abundance  of  nitrogenous  food,  bears  a  direct 
causative  relation  to  the  increase.  As  stated  under  Tumors,  the  active  agent 
in  the  production  of  cancer  remains  undiscovered.  Cancer  of  the  breast  is, 
generally  speaking,  a  disease  of  middle  and  advanced  life.  In  seventy  cases 
coming  under  my  observation  the  average  age  was  fifty  years:  It  is  occasion- 
ally observed  in  women  under  thirty  years  of  age ;  and  in  these  cases  runs  a 
particularly  malignant  course.  When  cancer  of  the  breast  is  complicated  by 
pregnancy  the  growth  is  especially  rapid  and  the  prognosis  unfavorable.  Vari- 
ous predisposing  causes  of  cancer  of  the  breast  are  local  trauma,  chronic  irri- 
tation— as  in  Paget's  disease,  already  described  under  Epithelioma  of  the 
Nipple.  Preexistent  inflammations,  either  acute,  suppurative,  or  chronic, 
predispose  to  the  formation  of  cancer.  The  nursing  of  several  infants  in 
succession,  the  existence  of  benign  tumors  of  the  breast  which  undergo  can- 
cerous degeneration,  notably  fibro-adenoma,  account  for  a  certain  proportion 
of  cases.  In  the  male  breast  cancer  is  a  rare  disease,  the  proportion  of  males 
to  females  being  about  1  to  100.  Various  forms  of  cancer  occur  in  the  breast, 
the  varieties  depending  largely  upon  the  relative  proportion  of  cellular  ele- 
ments and  fibrous  stroma.  Those  cancers  which  contain  much  fibrous  tissue 
and  but  few  alveoli  are  hard  tumors  of  slow  growth.  Those  which  contain 
many  large  alveoli  and  many  cells  with  but  little  fibrous  stroma  are  soft  tumors, 
and  usually  grow  rapidly. 

Billroth  divided  carcinoma  of  the  breast  into  four  types: 

1.  Acinous  Cancer. — The  structure  of  the  tumor  conforms  more  or  less  per- 
fectly to  that  of  an  acinous  gland.  It  occurs  in  the  breast  as  a  nodular  tumor, 
rather  soft  than  hard,  of  a  grayish-white  or  reddish-gray  color  on  section;  from 
the  surface  the  characteristic  cancer  juice  can  be  expressed  or  scraped.  The 
alveoli  are  quite  large,  the  stroma  is  moderate  or  small  in  amount,  and  densely 
infiltrated  with  small  round  cells.  The  softest  of  these  tumors  are  sometimes 
spoken  of  as  medullary  carcinoma.  (The  author  sees  no  reason  why  they 
should  be  placed  in  a  separate  group.)  The  tumor  is  prone  to  grow  rapidly;  to 
undergo  degenerative  changes  early ;  to  invade  the  skin ;  ulcerate  and  produce 
fungating  masses  of  tumor  tissue,  or  sloughing  putrid  craterlike  ulcers.  In- 
fection of  the  axillary  lymph  nodes  occurs  late,  as  does  constitutional  infection. 
The  secondary  tumors  resemble  the  primary  growth.  The  prognosis  of  this 
form  of  cancer  is  not  very  unfavorable.  The  experience  of  William  S.  Halsted 
upholds  this  view.  He  considers  the  prognosis  of  these  cases  better  after  opera- 
tion than  in  Types  2  and  3. 

2.  Carcinoma  simplex — Tubular  Cancer. — Carcinoma  simplex — tubular  can- 
cer— is  the  most  frequent  form  of  cancer  of  the  breast.     It  is  characterized  by 


686 


THE    BREAST 


greater  hardness  than  the  acinous  form,  by  a  tendency  to  rapid  infiltation, 
especially  of  the  skin  and  subcutaneous  tissues,  and  the  formation  of  multiple 
scattered  hard  nodules  in  the  skin,  which  coalesce  and  produce  a  boardlike  hard- 
ness of  the  soft  parts  covering  the  chest  wall,  to  which  the  infiltrated  tissues 
are  firmly  adherent  ("cancer  en  cuirasse").  Ulceration  and  retrogressive 
changes  in  the  tumor  tissue  (fatty  metamorphosis)  are  common.  The  arrange- 
ment of  the  alveoli  is  often  in  the  form  of  long,  slender  strings  of  cancer  cells ; 

in  other  places  oval,  rounded,  or 
irregular  spaces  exist  in  the  stro- 
ma, filled  with  tumor  cells. 

3.  Scirrhous  Carcinoma. — Scir- 
rhous carcinoma  has  been  sufficient- 
ly described  under  Tumors. 

4.  Colloid  Cancer. — Carcinoma 
gelatinosum  is  a  rare  form  of  the 
disease.  The  tumor  is  of  slow 
growth  and  not  markedly  malig- 
nant. It  is  characterized  by  a 
slimy  degeneration  of  the  stroma. 
This  degeneration  may  occupy  the 
entire  tumor  or  only  the  older  por- 
tions. In  some  cases  the  contents 
of  the  alveoli  undergo  fatty  or  cal- 
careous degeneration,  the  epithelia 
disappear.  The  tumor  is  soft, 
juicy,  friable,  semicystic. 

Adenocarcinoma.  —  Under  the 
head  Adenocarcinoma,  W.  S.  Hal- 
sted  described  a  form  of  cancer  of 
the  breast  characterized  by  the 
production  of  a  prominent  tumor 
mass  tending  at  times  to  become 
nearly  pedunculated.  Ulceration 
and  the  formation  of  fungating  granulations  are  common.  The  alveoli  of 
the  tumor  are  large  and  the  cells  occupy  their  periphery,  being  usually 
absent  from  the  centers.  Infection  of  axillary  lymph  nodes  occurs  late,  or  not 
at  all.  The  growth  is  not  very  malignant.  Halsted  considers  this  growth  iden- 
tical with  the  duct  cancer  of  the  English  and  with  the  villous  cancer  of  the 
French. 

Clinical  Course  and  Diagnosis  of  Cancer  of  the  Breast. — The  first  symp- 
toms noticed  by  the  patient  may  be  intermittent,  sharp,  lancinating  pain  felt 
in  the  breast,  radiating  to  the  shoulder  and  arm.  In  other  cases  a  nodule  is 
discovered  by  accident  in  the  breast ;  this  may  have  already  attained  some  size. 
The  nodule  is  situated  in  the  substance  of  the  gland,   and  may  occupy  any 


Fig.  247. — Scirrhous  Carcinoma  of  the  Breast, 
Showing  Atrophy  of  the  Breast  and  Retract- 
ing of  the  Nipple.  (New  York  Hospital,  ser- 
vice of  Dr.  Frank  Hartley.) 


TUMORS    OF   THE   BREAST 


687 


Fig.  248. — Scirrhous  Carcinoma  of  the  Breast  Extend- 
ing Upward  and  Outward,  Showing  Characteristic 
Atrophy  and  Puckering  of  the  Skin.  (Roosevelt 
Hospital,  collection  of  Dr.  Charles  McBurney.) 


position.  The  periphery  of  the  upper  and  outer  quadrant  is  its  site  in  more 
than  half  the  cases.  Upon  palpation  the  lump  is  felt  to  be  of  rather  uneven 
outline,  usually  hard,  rarely 
soft,  and  intimately  adherent 
to  the  structure  of  the  gland. 
One  of  the  most  characteristic 
signs  of  cancer  of  the  breast  is 
flattening  or  retraction  of  the 
nipple,  caused  by  contraction 
of  the  fibrous  stroma  of  the 
cancer,  involving  the  walls  of 
the  milk-ducts  and  their  lym- 
phatics. Of  this  sign  it  is  to 
be  remembered  that  it  is  not 
pathognomonic  of  cancer,  since 
a  former  abscess  of  the  breast 
or  interstitial  mastitis  may  pro- 
duce it ;  nor  is  its  absence  of 
any  special  value  in  the  exclu- 
sion of  cancer.  In  some  cases 
a  dimple  will  appear  in  the  skin 
of  the  breast  from  a  similar 
cause,  or  the  skin  will  be  wrinkled  over  a  larger  or  smaller  area.  In  very  early 
cases  the  attachment  of  the  fibrous  bundles  of  subcutaneous  tissue  to  the  tumor 
will  only  be  appreciated  by  attempting  to  move  the  skin  over  the  tumor,  when 

slight  puckering  or  wrinkling  of 
the  skin  will  be  observed.  Ad- 
hesion to  the  glandular  structure 
itself  is  readily  made  out  by 
grasping  the  tumor  with  the 
fingers  and  attempting  to  move 
it.  The  commonest  form  of  be- 
nign tumor — one  or  other  of  the 
varieties  of  fibro-adenoma — will 
be  felt  to  slip  about  quite  freely 
in  the  substance  of  the  gland,  or 
even  to  be  quite  detached  from 
it.  If  the  growth  is  cancer, 
gland  and  tumor  move  as  one 
mass.  Many  cancers  of  the  breast 
form  adhesions  to  the  pectoralis 
fascia  quite  early;  others  only 
after  they  have  existed  for  many 
months.      The    presence    or    ab- 


Fig.  249. — Ulcerated  Adenocarcinoma  of  the  Breast. 
(Collection  of  Dr.  Charles  McBurney.) 


688 


THE    BREAST 


Fig.  250. — Adenocarcinoma  or  the  Breast. 
lection  of  Dr.  Charles  McBurney.) 


(Col- 


sence  of  such  adhesions  is  best  appreciated  by  abducting  the  arm  to  the  horizon- 
tal position,  thus  putting  the  pectoralis  major  a  little  upon  the  stretch,  grasping 
the  breast  with  the  whole  hand  and  attempting  to  move  it  back  and  forth  in  the 

direction  of  the  fibers  of  the  pec- 
toralis major  muscle.  If  no  adhe- 
sions are  present,  the  movement  will 
be  free ;  if  the  growth  is  adherent, 
a  sliding  movement  will  be  limited 
or  absent.  If  the  growth  is  already 
adherent  to  the  thoracic  wall  (ster- 
num or  ribs),  it  will  be  immovable, 
irrespective  of  the  position  of  the 
arm. 

The  axillary  glands  become  in- 
fected and  palpable  after  very  vari- 
able periods  in  cancer  of  the  breast ; 
in  some  cases  in  a  few  months,  in 
others  not  for  a  year  or  more.  I 
have  seen  cases  of  atrophic  scirrhus  of  the  breast  in  which  the  glands  remained 
unaffected  for  years.  Because  the  glands  are  not  palpable,  it  is  not  to  be  con- 
cluded that  they  are  not  diseased,  since  it  has  been  shown  by  Halsted  that  they 
may  be  the  seat  of  carcinoma  in  a  few  weeks  after  the  discovery  of  the  tumor. 
The  first  gland  to  be  affected  is  usually  the  one  situated  beneath  the  border  of 
the  pectoralis  major,  over  the 
third  rib  or  third  space.  Pal- 
pation of  the  axilla  to  detect 
such  glands  is  best  made  with 
the  arm  hanging  by  the  side. 
The  nodules,  if  cancerous,  are 
hard  and  insensitive.  Early 
they  are  small  and  movable ; 
they  may  escape  detection  if  the 
patient  is  fat.  Later  they  be- 
come large  and  fixed  to  the  ribs 
or  to  the  vessels ;  they  then  form 
stony  immovable  masses,  of  ab- 
solutely bad  omen.  It  is  well 
in  every  case  to  examine  both 
axillae.  Late  in  the  disease 
pressure  upon  the  nerve  trunks 
of    the    axilla    causes    horrible, 

torturing  pain,  and  weakness  of  the  arm.  Pressure  upon  the  axillary  vein,  hard 
edema  of  the  hand  and  arm.  Involvement  of  the  supraclavicular  and  cervical 
glands  occurs  after  those  in  the  axilla.    If  they  are  palpably  enlarged,  the  prog- 


^9 

/ 

w 

Fig.  251. — Carcinoma  Simplex  of  the  Breast,  Show- 
ing Rather  Massive  Tumor  and  Retraction  of 
the  Nipple.     (Collection  of  Dr.  Charles  McBurney.) 


TUMORS    OF   THE    BREAST 


689 


nosis  is  very  unfavorable  for  cure.  The  increase  in  size  of  the  tumor  itself 
varies  with  the  variety  of  cancer.  The  soft  cellular  forms  grow  rapidly  and 
may  attain  a  considerable  size  in  a  few  months.  Scirrhus  grows  slowly,  and 
instead  of  an  increase  the  whole  breast  may  show  a  decided  diminution  in  size. 
The  involvement  of  the  skin  varies  much  in  different  cases.  In  the  soft  acinous 
cancers  it  is  early  adherent  and  boggy,  then  reddened  and  rapidly  ulcerated, 
with  the  production  of  a  crateriform  ulcer,  with  a  sloughing,  often  putrid,  base; 
or  the  formation  of  a  fungating  bleeding  mass  of  granulation  tissue. 

In  carcinoma  simplex  multiple  nodules  are  often  formed  in  the  skin  of 
the  breast  and  the  vicinity — a  sign  of  very  bad  omen.  In  this  form,  also, 
ulceration  is  frequent.  In  scirrhus  it  is  usually  long  delayed  and  super- 
ficial. The  condition  known  as  "  cancer  en  cuirasse  "  is  especially  common  in 
carcinoma  simplex,  although  it 
may  occur  in  any  of  the  forms 
of  the  disease  if  the  patient 
survive  long  enough.  Cancer- 
ous nodules  appear  in  the  skin 
of  the  breast,  the  axilla,  over  the 
sternum,  and,  later,  are  scat- 
tered over  the  entire  thoracic 
wall,  front  and  rear.  A  dense 
boardlike  infiltration  steadily  ad- 
vances from  the  tumor  in  the 
breast  in  all  directions.  New 
nodules  appear,  and  finally  coa- 
lesce until  a  half  or  more  of 
the  thoracic  wall  is  a  solid  mass 
of  cancerous  infiltration. 

The  regular  history  of  can- 
cer of  the  breast  is  that  of 
steady  progress.  The  tumor 
tissue  invades,  infiltrates,  re- 
places, and  destroys  the  surrounding  tissues  without  regard  to  their  char- 
acter ;  at  the  same  time  lymphatic  infection  goes  on  to  the  axilla  and  to 
the  pectoral  muscles,  the  intercostal  spaces,  the  sternum,  and  the  pleura. 
Dissemination  through  the  lymph  channels  and  blood  current  causes  second- 
ary tumors  in  distant  regions — the  liver,  the  spine,  the  bones,  the  brain,  etc. 
Retrogressive  changes  in  the  primary  tumor  lead  to  the  absorption  of  toxic 
products,  to  ulceration,  chronic  sepsis,  and  hemorrhage.  In  many  cases 
there  is  produced,  quite  early  in  the  disease,  before  any  secondary  tumors 
can  be  found,  a  notable  change  in  the  general  health ;  the  patients  become 
anemic  and  have  a  peculiar  waxy  pallor;  they  feel  weak,  suffer  from  impaired 
digestion,  emaciation  is  often  absent  until  very  late.  As  the  disease  progresses, 
pain,  sepsis,  hemorrhage,  and  the  symptoms  produced  by  the  secondary  tumors 
45 


Fig.  252. — Ulcerated  Carcinoma  of  the  Breast,  In- 
operable. (New  York  Hospital  Collection,  service 
of  Dr.  F.  W.  Murray.) 


690  THE   BEEAST 

gradually  destroy  life — sometimes  by  exhaustion,  usually  by  a  combination  of 
the  causes  mentioned. 

Practical  Suggestions. — In  regard  to  the  diagnosis  of  tumors  of  the  female 
breast  in  general,  a  few  words  may  be  added  of  a  practical  character.  Cancer 
is  much  the  most  frequent  tumor  of  the  breast.  Any  tumor  appearing  in  the 
breast  in  a  woman  forty  years  of  age  or  more  is  probably  a  cancer.  A  tumor 
which  has  remained  small  for  years  and  then  begins  to  grow  rapidly,  has 
almost  certainly  undergone  malignant  degeneration.  Experience  shows  that 
many  benign  tumors  undergo  such  changes,  notably  at  the  time  of  the  meno- 
pause. A  tumor  of  the  breast  of  any  sort  at  any  age  is  a  source  of  discomfort 
and  anxiety  to  its  possessor,  as  well  as  a  possible  menace  to  life,  and  should  be 
removed  by  operation,  unless  distinct  physical  contraindications  exist.  In 
the  case  of  a  tumor,  the  nature  of  which  is  doubtful,  temporizing  measures  are 
absolutely  inexcusable  on  the  part  of  a  medical  attendant.  The  proper  diag- 
nostic measures  to  pursue  in  such  cases  are  incision  and  inspection  of  the 
tumor.  If  doubt  still  remains,  removal  of  a  small  portion ;  examination  of  a 
frozen  section,  then  and  there,  and  an  operation  in  accord  with  the  findings 
of  the  pathologist.  By  early  and  thorough  ojDeration  the  prognosis  of  cancer 
of  the  breast  has  been  greatly  improved  during  recent  years.  A  positive  diag- 
nosis of  every  tumor  of  the  breast  is  therefore  desirable  at  the  earliest  possible 
moment. 

Contraindications  to  Operation. — In  what  cases  should  we  refrain  from 
operating  for  carcinoma  of  the  breast  ?  Atrophic  scirrhus  of  the  breast  in  very 
old  and  feeble  women  may  well  be  let  alone;  the  disease  may  exist  for  years 
without  destroying  life,  or  even  exposing  the  individual  to  great  suffering. 
The  presence  of  metastatic  tumors,  or  of  marked  cachexia,  indicates  that  an 
operation  would  be  useless.  Large  immovable  nodules  in  the  axilla,  the  pres- 
ence of  a  cancerous  boss  upon  the  sternum,  matted  carcinomatous  lymph  nodes 
in  the  neck,  indicate  hopeless  conditions.  Extensive  infection  of  the  skin  and 
the  presence  of  secondary  cancerous  nodules  around  the  primary  growth  render 
the  prognosis  unfavorable,  and  may  be  distinct  contraindications.  In  a  general 
way,  when  it  seems  possible  to  remove  the  entire  disease,  we  should  operate, 
otherwise  not.  As  a  palliative  measure  superficial  ulcerating  growths  which 
can  be  removed  in  their  entirety,  may,  sometimes,  be  so  removed,  with  tem- 
porary benefit,  though  we  know  that  in  other  directions  the  disease  is  beyond 
our  reach. 

Tumors  of  the  Male  Breast. — The  occurrence  of  tumors  of  the  breast  is  a 
hundred  times  more  frequent  in  women  than  in  men,  and  of  the  tumors  of 
the  male  breast  only  a  small  percentage  are  carcinomata.  Of  benign  tumors, 
fibro-adenoma,  cystic  adenoma,  submammary  lipoma,  as  well  as  tuberculosis 
and  gumma  may  occur.  Carcinoma  develops  between  the  ages  of  forty  to 
sixty  years  in  most  cases.  The  disease  does  not  differ  in  any  essential  from 
what  we  find  in  the  female. 


CHAPTER    XXIII 
THE  ABDOMEN 

The  diagnosis  of  the  injuries  and  surgical  diseases  of  the  abdomen  is  one 
of  the  most  interesting,  and  sometimes  one  of  the  most  difficult,  tasks  the 
surgeon  is  called  upon  to  perform.  The  responsibilities  in  the  given  case  are 
often  heavy,  since  the  life  of  the  patient  may  depend,  both  in  injury  and 
disease,  upon  the  immediate  decision  of  the  question,  Shall  the  abdomen  be 
opened  or  not  ?  In  some  cases  the  answer  is  easily  arrived  at ;  in  others,  a 
high  degree  of  skill  and  judgment  based  upon  a  wide  experience  are  called 
for  to  arrive  at  a  correct  decision;  and  in  still  others,  the  best  men  alive  may 
err.  In  abdominal  diseases,  the  patient  will  usually  have  been  in  charge  of 
a  medical  man,  who  furnishes  the  history  of  the  case  and  frequently  the 
diagnosis.  The  choice,  for  or  against  operative  interference,  rests  with  the 
surgeon.  Time  was  when  a  large  proportion  of  the  medical  profession  shared 
with  the  laity  a  decided  fear  of  and  prejudice  against  early  operative  inter- 
ference in  diseases  of  the  abdominal  organs.  The  good  results  following  early 
operation  in  many  acute  and  chronic  abdominal  conditions,  together  with  the 
dangers  of  delay,  and  the  utter  hopelessness  of  interference  when  malignant 
disease  is  far  advanced,  or  the  patient  is  exhausted  by  septic  poisoning  or  by 
diffuse  purulent  peritonitis  with  paralysis  of  the  intestine,  are  now  very  gen- 
erally recognized  by  the  more  intelligent  members  of  the  medical  profession, 
and  even  by  the  laity.  The  surgeon  may  therefore  expect  to  be  called  at  a 
favorable  time,  and  to  receive  hearty  support  from  the  family  medical  attend- 
ant in  a  large  proportion  of  the  cases  he  is  asked  to  see.  Many  cases  are  met 
with  such  that  the  surgeon,  although  ignorant  of  the  precise  seat  and  nature 
of  the  lesion,  is  entirely  justified  in  operating  on  the  ground  that  the  disease 
is  evidently  of  a  serious  character,  only  to  be  relieved,  if  at  all,  by  operation, 
and  that  the  risk  of  exploration  is  slight,  The  various  forms  of  intestinal 
obstruction,  cases  of  acute  purulent  peritonitis  of  obscure  origin,  many  injuries 
of  the  abdomen,  a  considerable  number  of  abdominal  tumors,  and  numerous 
other  conditions  may  fall  into  this  category.  Before  describing  the  methods 
used  in  the  diagnosis  of  intra-abdominal  lesions,  it  will  be  necessary  to  discuss 
the  injuries  and  diseases  of  the  abdominal  wall.  Lesions  of  the  viscera  and 
of  the  parietes  are  often  associated,  but  many  of  the  latter  occur  alone,  and 
demand,  therefore,  separate  consideration. 

691 


692  THE   ABDOMEN 

INJURIES   OF   THE   ABDOMINAL   WALL 

Injuries  of  the  abdominal  wall  niay  be  subcutaneous  or  open  wounds;  the 
latter  may  be  penetrating  or  nonpenetrating. 

Contusions. — The  slightest  form  of  contusion  occurs  from  slight  or  moderate 
blows  upon  the  abdomen,  and  is  followed  by  the  escape  of  blood  into  the  sub- 
cutaneous tissues,  ecchymosis,  slight  pain,  and  tenderness.  These  signs  and 
symptoms  usually  disappear  in  a  few  days.  If  a  considerable  vessel  or  several 
vessels  are  ruptured,  a  fluctuating  hematoma  may  form  beneath  the  skin.  The 
effused  blood  tends  to  spread  by  gravity,  and  to  appear  as  a  characteristic  blue 
discoloration  on  the  lower  part  of  the  abdomen,  the  thighs,  the  flanks,  and 
sometimes  upon  the  back.  In  some  cases,  when  the  violence  is  more  severe, 
bleeding  may  take  place  behind  the  abdominal  muscles  in  the  preperitoneal 
fatty  tissue.  In  these  the  blood  may  find  its  way  downward,  and  appear  after 
several  days  below  Poupart's  ligament  in  the  thigh ;  such  bleeding  may  be 
large  in  amount. 

Shock. — After  severe  contusions  of  the  abdomen,  the  condition  known  as 
abdominal  shock  is  observed ;  the  symptoms  are  believed  to  be  due  to  irritation 
of  the  peripheral  nerves,  causing  a  reflex  paralysis  of  the  vasomotor  center  of 
the  medulla.  The  patients  fall  immediately  into  a  condition  of  collapse.  The 
features  are  pale,  drawn,  and  pinched ;  the  mucous  membranes  are  blanched, 
the  expression  dull  and  apathetic.  Cerebration  is  slow  and  imperfect.  The 
pupils  of  the  eyes  are  dilated,  and  respond  but  slowly  to  light.  The  extremities 
are  cold.  There  may  be  nausea  and  vomiting.  The  temperature  of  the  body 
is  often  subnormal,  the  pulse  slow  or  rapid,  thready,  and  compressible.  Respi- 
ration is  shallow,  irregular,  or  sighing;  it  may  be  of  the  Cheyne-Stokes  type. 
(See  Shock.)  From  this  condition  the  patients  usually  rally  after  minutes  or 
hours,  unless  some  gross  lesion  of  the  abdominal  contents  is  present.  A  few 
cases  only  have  resulted  fatally,  apparently  from  the  condition  of  shock  alone, 
death  being  preceded  by  unconsciousness  and  progressive  heart-failure.  All 
these  cases  give  the  surgeon  anxiety  and  demand  careful  watching  for  signs 
of  intra-abdominal  bleeding  or  injury  of  hollow  organs. 

Still  another  condition  occurs  from  blows  upon  the  upper  part  of  the  abdo- 
men and  over  the  lower  ribs,  the  nature  of  which  is  not  entirely  clear.  An 
individual  receives  a  blow  in  the  epigastrium — as  from  a  fist  while  boxing. 
He  falls  to  his  knees  or  prone  upon  the  ground,  and  for  some  seconds  is  almost 
unable  to  breathe;  there  is  a  sense  of  impending  suffocation.  The  expression 
of  the  face  is  drawn  and  anxious.  The  accessory  muscles  of  respiration  are 
powerfully  contracted ;  after  several  ineffectual  gasps,  he  succeeds  in  taking  a 
labored  inspiration,  and  after  seconds  or  minutes  breathing  gradually  becomes 
normal.  For  minutes  or  hours  he  feels  more  or  less  muscular  weakness.  It 
seems  not  improbable  that  temporary  paralysis  of  the  diaphragm,  induced  in 
a  reflex  manner  by  the  mechanical  irritation  of  the  sympathetic  nerves  of  the 
abdomen,  may  account  for  the  condition. 


INJURIES    OF   THE   ABDOMINAL   WALL  693 

Rupture  ok  the  Abdominal  Muscles. — Rupture  of  the  abdominal  mus- 
cles occurs  as  the  result  of  contusions  of  the  abdominal  wall,  very  rarely  as 
the  result  of  muscular  effort,  in  healthy  persons.  Among  alcoholics  and  during 
acute  infectious  diseases — notably  typhoid  fever — rupture  of  the  rectus  ab- 
dominis is  not  a  very  infrequent  accident.  The  rectus  abdominis  is  ruptured 
in  most  instances  below  the  umbilicus.  The  number  of  cases  in  which  the 
oblique  or  transverse  muscles  have  been  ruptured,  is  very  small.  The  diag- 
nosis is  to  be  made  from  the  history  of  a  blow,  a  sudden  muscular  strain,  or 
a  violent  hyperextension  of  the  trunk.  The  patient  will  have  felt  a  sharp 
pain  at  the  point  of  rupture,  and  often  a  sense  of  something  giving  way.  There 
will  be  localized  pain  and  tenderness.  If  the  patient  is  not  too  fat,  palpation 
will  discover  a  pit  or  sense  of  diminished  resistance  at  the  point  of  rupture; 
sometimes  a  sense  of  fullness  above  or  below.  In  ordinary  cases  the  rupture 
heals  by  the  production  of  a  scar  in  the  substance  of  the  muscle.  If  the 
rupture  has  occurred  during  typhoid,  or  some  other  infectious  disease,  sup- 
puration may  occur  by  hematogenous  infection.  In  some  cases  the  anterior 
layer  of  the  rectus  sheath  may  be  ruptured  by  blunt  violence.  The  belly  of 
the  muscle  may  protrude  through  the  rent  and  be  palpable  as  a  tender  tumor. 
In  all  cases  of  contusion  of  the  abdomen,  even  if  not  very  severe,  there  is  risk 
of  injury  to  the  viscera — notably  to  the  intestine.  The  nature  of  the  accident 
should  be  inquired  into  carefully.  Those  injuries  in  which  the  abdomen  is 
compressed  against  a  solid  support — as  the  ground,  a  wall,  a  railway-car  buffer, 
etc. — are  always  to  be  regarded  as  serious.  A  long  continuance  or  increase  in 
the  symptoms  of  shock,  or  a  return  of  such  symptoms  after  hours  or  days, 
points  to  intra-abdominal  hemorrhage  or  rupture  of  the  gut;  general  abdom- 
inal pain  and  muscular  rigidity,  extending  beyond  the  injured  area,  to  rupture 
of  the  gut  and  peritonitis;  the  general  symptoms  of  hemorrhage,  abdominal 
pain,  and  dullness  on  percussion  in  the  flanks  to  free  blood  in  the  belly.  It  is 
to  be  borne  in  mind  that  contused  gut  may  slough  and  permit  the  escape  of 
intestinal  contents  after  many  days ;  hence,  contusions  of  the  belly  are  always 
to  be  regarded  as  possibly  dangerous  injuries. 

Wounds  of  the  Abdominal  Wall. — Nonpenetrating,  incised  wounds  of  the 
abdominal  wall  are  not  dangerous  injuries,  if  clean.  The  only  important 
vessels  likely  to  be  injured  are  the  deep  epigastric  artery  in  front  and  the 
lumbar  arteries  behind.  The  deep  epigastric  is  given  off  from  the  external 
iliac  opposite  the  center  of  Poupart's  ligament,  and  runs  upward  and  inward 
behind  the  rectus  muscle,  which  it  supplies,  to  anastomose  in  the  epigastrium 
with  the  internal  mammary.  If  cut,  both  ends  of  the  divided  vessel  should 
be  tied.  Wounds  of  the  lumbar  arteries  are  rare.  The  superficial  epigastric, 
if  cut  between  Poupart's  ligament  and  the  umbilicus,  scarcely  gives  rise  to 
serious  bleeding.  In  many  instances  the  nature  and  extent  of  the  injury  will 
be  readily  evident  on  inspection.  Wounds  of  the  sheath  of  the  rectus,  of  the 
external  oblique  aponeurosis,  of  the  muscular  bellies,  for  example.  Such 
wounds  are  quite  common  among  negroes  in  the  city  of  New  York.      They 


694  THE   ABDOMEN 

are  usually  razor  cuts,  and  run  transversely  or  obliquely  across  the  belly,  and 
often  cut  the  intestine.  Among  Italians,  narrow  stab  wounds  are  commonly 
observed;  they  are  made  with  pen-knives,  slender  daggers,  or  sharpened  files. 
Incised  and  stab  wounds  made  with  carving  knives,  butchers'  knives,  and  sailors' 
sheath  knives  are  quite  commonly  seen  in  the  hospitals  of  ISTew  York  City. 
In  a  large  proportion  of  the  cases  the  peritoneum  is  opened  and  one  or  other 
of  the  abdominal  viscera  injured,  most  commonly  the  small  intestine,  sometimes 
the  stomach  and  colon,  occasionally  the  liver,  rarely  the  kidney.  It  is  stated 
that  among  miners  in  Mexico  assaults  with  daggers  are  not  infrequent;  the 
victim  is  usually  stabbed  from  behind,  and  the  ascending  or  descending  colon 
is  frequently  wounded.  When  the  nature  of  the  weapon  or  the  symptoms  make 
it  probable  that  the  wound  opens  the  peritoneum,  it  should  be  explored  by 
direct  vision,  and  with  every  possible  aseptic  precaution,  best  under  a  general 
anesthetic,  the  original  wound  being  enlarged  for  the  purpose,  if  necessary. 
If  a  hole  of  some  size  exists  in  the  peritoneum,  omentum,  or,  less  often,  intes- 
tine may  be  found  prolapsed  in  the  external  wound.  (See  Penetrating  Wounds 
of  the  Abdomen.) 

Contused  and  Lacerated  Wounds  of  the  Abdominal  Waul. — Contused 
and  lacerated  wounds  of  the  abdominal  wall  are  produced  by  blunt  violence, 
by  a  blow  of  a  horse's  hoof,  by  machinery  accidents,  by  explosions,  by  the 
falling  of  iron  beams,  etc.  They  are  often  attended  by  extensive  stripping  of 
,  the  tissues  and  by  loss  of  substance,  so  that  the  muscles  may  be  laid  bare  over 
a  considerable  area.  When  produced  by  purely  blunt  violence  they  rarely,  if 
ever,  open  the  peritoneum.  No  difficulties  exist  in  the  diagnosis,  as  far  as 
the  abdominal  wall  is  concerned.     Foreign  bodies  should  be  sought  for. 

Gunshot  Wounds  of  the  Abdominal  Wall. — Gunshot  wounds  of  the 
abdominal  wall  usually  penetrate  the  peritoneum ;  such  will  be  spoken  of  under 
injuries  of  the  abdominal  contents.  Occasionally  a  tangential  shot  may  fail 
to  do  so,  or  a  spent  bullet  may  cause  a  more  or  less  superficial  contused  wound ; 
only  rarely  a  bullet,  traveling  at  low  velocity,  may  be  deflected  by  fascial 
planes  and  follow  the  contour  of  the  abdominal  wall  for  a  variable  distance, 
to  lodge  or  emerge.  In  cases  of  doubt,  palpation  or  the  X-rays  will  locate 
the  missile,  if  present.  The  signs  and  symptoms  of  injury  of  the  abdominal 
contents  will  be  absent.  It  should  not  be  forgotten  that  a  shell  fragment,  or 
even  a  bullet,  may  cause  rupture  of  the  gut  without  perforating  the  abdom- 
inal wall. 

Foreign  Bodies  in  the  Abdominal  Wall. — Foreign  bodies  in  the  abdominal 
wall  may  be  introduced  from  without  through  a  wound ;  such  are  splinters  of 
wood,  portions  of  clothing,  needles,  a  portion  of  a  knife  blade,  etc. ;  or  they 
may  have  been  swallowed,  and  have  ulcerated  through  the  intestine,  to  appear 
usually  in  the  region  of  the  umbilicus.  In  the  first  class  the  foreign  body,  if 
bearing  pyogenic  germs,  causes  the  wound  to  suppurate  until  it  is  extracted. 
In  the  second  the  intestine  may  become  adherent  to  the  abdominal  wall,  and 
an  abscess  may  form  from  which  the  body  is  extracted,  leaving  a  fecal  fistula 


DISEASES    OF    THE    ABDOMINAL   WALL  695 

behind,  which  may  close  spontaneously  or  not;  or  the  abscess,  when  opened, 
may  have  ceased  to  communicate  with  the  gut,  or  the  foreign  body — a  needle, 
for  example — may  merely  cause  a  point  of  local  pain  and  tenderness  in  the 
abdominal  wall  without  inflammatory  signs. 

DISEASES   OF   THE   ABDOMINAL   WALL 

Inflammations. —  Furuncles,  superficial  abscesses,  occasionally  carbuncles  and 
diffuse  phlegmonous  processes,  occur  in  the  skin  and  subcutaneous  tissues  of 
the  abdominal  wall  as  in  other  situations.  They  present  no  special  diagnostic 
features.  (See  these  topics  in  chapters  on  General  Surgery.)  Scalds  and 
burns  of  the  abdominal  wall,  from  steam,  flame,  acids,  and  alkalies,  are  not 
rare.  I  saw  a  man  die  in  three  days  from  erysipelas  of  the  abdominal  wall 
following  a  scald  of  the  abdominal  wall  and  scrotum. 

Deep-seated  Inflammations. — The  deep-seated  inflammations  are  of 
more  interest.  Suppuration  in  the  deeper  structures  of  the  abdominal  wall 
may  be  due  to  primary  infections  from  open  wounds,  to  hematogenous  infec- 
tions in  the  course  of  infectious  diseases,  to  metastatic  infections  in  the  course 
of  pyemia.  In  many  cases  the  infection  is  due  to  the  extension  of  suppurative 
processes  from  near  or  distant  organs  or  structures,  or  to  traumatisms  involv- 
ing the  bladder  or  the  intestine.  Certain  of  these  inflammations  occur  near 
the  middle  line  of  the  belly  in  front,  between  the  umbilicus  and  the  pubes. 
Among  the  primary  infections  may  be  mentioned  suppuration  in  the  rectus 
sheath,  usually  in  front  of  the  muscular  bellies  and  below  the  umbilicus.  Such 
suppuration  may  follow  rupture  of  the  muscle  in  the  course  of  typhoid  fever. 
In  addition  to  the  general  signs  of  sepsis,  more  or  less  marked,  there  will  be 
local  pain  and  tenderness  and  the  formation  of  a  tumor  which  becomes  more 
prominent  and  less  movable  when  the  recti  are  put  in  action — as  in  rising  to  a 
sitting  posture.  A  subcutaneous  abscess  may  usually  be  moved  a  little  irre- 
spective of  the  action  of  the  recti.  The  tumor  may  be  unilateral  or  bilateral, 
and  will  correspond  in  situation  and  contour  with  the  rectus  sheath. 

Suppuration  behind  the  muscles  may  occur  in  several  situations:  (1) 
Around  the  umbilicus;  (2)  in  the  loose  connective  tissues  behind  the  recti; 
(3)  in  the  prevesical  space  (cavum  Retzii)  ;  (4)  in  the  preperitoneal  con- 
nective tissues.  It  is  to  be  borne  in  mind,  that  while  anatomically  these 
several  spaces  can  be  recognized  as  distinct  and  separate,  and  clinically  inflam- 
mations are  in  many  cases  limited  by  these  anatomical  boundaries,  yet  in  other 
instances  infection  may  involve  two  or  more  of  the  spaces  at  the  same  time. 
The  most  important  of  these  spaces  is  the  space  of  Retzius,  or  prevesical  space. 
Suppuration  may  occur  here  from  a  variety  of  causes,  among  them  trauma, 
either  subcutaneous  or  open,  to  the  lower  part  of  the  belly,  with  the  formation 
of  a  hematoma  in  the  prevesical  space,  which  becomes  infected  and  forms  an 
abscess.  I  have  seen  abscesses  in  this  region  follow  fractures  of  the  pelvis, 
with  or  without  evident  rupture  of  the  membranous  urethra  or  bladder.     When 


696 


THE    ABDOMEN 


extensive  extravasation  of  urine  takes  place,  the  symptoms  of  general  intoxica- 
tion of  a  virulent  character  are  added  to  the  local  signs.  Sometimes  we  are 
unable  to  trace  the  cause  of  the  infection,  although  some  local  cause  probably 
exists  in  nearly  all  cases.     Among  the  causes  of  secondary  suppuration  in  the 


Fig.  253. — Large  Abscess  of  the  Abdominal  Wall  Originating  in  the  Sheath  of  the  Rectus 
Muscle.      (New  York  Hospital  Collection,  sendee  of  Dr.  F.  W.  Murray.) 


prevesical  space  may  be  mentioned  suppurative  processes  of  the  prostate  and 
seminal  vesicles ;  cystitis  and  pericystitis,  whether  of  gonorrheal  or  other  ori- 
gin; ulceration  of  the  bladder  wall;  osteomyelitis  of  the  pelvic  bones;  suppura- 
tive inflammation  of  the  retroperitoneal  glands  following  chancroidal  or  ordi- 
nary pyogenic  infection;  ulcerative  processes  of  the  sigmoid  flexure;  possibly, 
also,  of  the  vermiform  appendix. 

A  so-called  hygroma  of  the  prevesical  space  was  described  by  Guyon,  who 
has  seen  several  cases. 

Signs  and  Symptoms  of  Acute  Suppuration  in  the  Prevesical  Space. — The 
signs  and  symptoms  of  acute  suppuration  in  the  prevesical  space  are  fairly 
characteristic;   the  ordinary  constitutional   symptoms  of  septic   infection   are 


DISEASES    OF   THE   ABDOMINAL   WALL  697 

present;  in  addition  there  may  be  symptoms  of  peritoneal  irritation,  nausea, 
and  vomiting'.  The  pressure  upon  the  bladder  causes  painful  and  often  diffi- 
cult urination  or  retention  of  urine.  There  is  pain  in  the  lower  part  of  the 
belly,  of  an  intense  character,  so  that  the  patient  may  lie  with  his  knees  drawn 
up,  as  in  some  cases  of  peritonitis.  Upon  inspection  and  palpation  a  rounded, 
tender  tumor  can  be  seen  and  felt  above  the  pubes,  resembling  in  situation  and 
contour  a  distended  bladder.  Evacuation  of  the  bladder  with  a  catheter  does 
not  cause  the  tumor  to  disappear.  The  tumor  gives  a  flat  note  upon  light 
percussion.     The  introduction  of  an  aspirating  needle  withdraws  pus. 

Tuberculosis  of  the  Space  of  Retzius. — Tuberculosis  of  the  space  of  Retzius 
has  been  observed  secondary  to  tuberculosis  of  the  recti  muscles.  Acute  symp- 
toms are  wanting. 

Suppuration  Behind  the  Recti. — Suppuration  behind  the  recti  in  the  sub- 
muscular  or  in  the  preperitoneal  tissues  is  occasionally  observed  as  a  primary 
condition  without  evident  cause.  The  tumor  has  a  higher  situation  than  those 
just  described ;  it  is  broader  above  toward  the  umbilicus,  and  tapers  off  toward 
the  pubes.  Symptoms  of  pressure  upon  the  bladder  are  absent ;  urination  is 
not  affected.  In  a  case  I  operated  on  some  years  ago  the  patient  was  an  elderly 
man,"  who  had  previously  enjoyed  good  health.  He  entered  the  hospital  suf- 
fering from  pain  in  the  lower  part  of  the  abdomen  and  moderate  sepsis.  A 
rounded,  painful,  tender  mass  could  be  felt  in  the  abdomen,  extending  from 
the  umbilicus  to  the  pubes,  flat  on  percussion.  Incision  evacuated  a  pint  or 
more  of  pus  lying  behind  the  recti  muscles,  above  the  bladder  and  in  front 
of  the  peritoneum.  !No  cause  could  be  found  for  the  abscess,  which  healed 
in  due  course. 

Deep-seated  Suppuration  in  the  Flanks. — Deep-seated  suppurative  processes 
in  the  lateral  regions  of  the  abdomen  may  be  due  to  extension  from  a  great 
variety  of  lesions.  Those  proceeding  from  the  kidney  or  from  the  perirenal 
connective  tissues  present  in  front  of  the  outer  border  of  the  quadratus  lum- 
borum  muscle.  In  a  good  many  cases  the  kidney  itself  is  not  involved.  The 
deep  origin  of  the  process  renders  an  early  diagnosis  difficult  without  a  history 
of  injury  or  the  signs  of  a  suppurative  lesion  of  the  kidney  (pyuria,  etc.). 
There  will  be  general  symptoms  of  sepsis,  pain,  and  deep  tenderness  in  the 
loin  below  the  ribs,  and  a  sense  of  resistance  on  bimanual  palpation  of  the  loin. 
When  the  abscess  becomes  subcutaneous,  a  tender,  fluctuating  tumor  will  be 
formed.  An  aspirating  needle  may  be  cautiously  used  to  establish  the  diag- 
nosis. Sometimes  these  abscesses  develop  quite  slowly;  several  weeks  may 
elapse  after  the  commencement  of  the  symptoms  before  the  local  signs  permit 
a  positive  diagnosis.  This  is  notably  true  in  stout  persons,  Avhere  deep-seated 
palpation  of  the  abdomen  is  difficult.  I  recall  a  case  of  this  kind  in  a  physician 
who  had  tenderness  and  pain  beneath  his  short  ribs,  and  moderate  symptoms 
of  sepsis,  for  several  weeks  before  pus  could  be  obtained  through  a  long  needle. 
No  cause  could  be  found  for  this  abscess.     (See  also  Perineal  Inflammations.) 

Suppurative  processes,   acute  or  chronic,   arising  from  the   vertebra?   and 


698  THE   ABDOMEN 

ribs  may  present  in  the  same  region ;  concomitant  signs  and  symptoms  must 
be  sought  for.  In  the  iliac  region  inflammatory  tumors  in  great  variety  may 
become  superficial.  Among  them  may  be  mentioned  abscesses  from  the  appen- 
dix, from  the  uterine  aclnexa,  and  from  the  bladder ;  inflamed  aneurisms  of  the 
iliac  vessels;  abscesses  from  the  kidney  and  ureter,  from  the  pelvic  bones,  and 
from  caries  of  the  spinal  vertebra?;  perforations  of  tuberculous  or  malignant 
growths  of  the  ileum,  cecum,  and  ascending  colon  on  the  right  side,  of  the 
sigmoid  flexure  on  the  left;  actinomycosis  of  the  cecum,  etc.  The  diagnosis 
of  some  of  these  conditions  is  not  difficult  from  the  history  and  physical  signs. 
If  the  suppurative  process  is  acute,  the  presence  of  pus  can  usually  be  deter- 
mined by  simple  methods  of  examination;  to  determine  its  origin  may  be  quite 
difficult.  In  chronic  cases  the  diagnosis  may  be  very  puzzling;  the  history, 
the  functional  disturbances  of  special  organs,  if  present,  may  aid.  Often  the 
diagnosis  will  only  be  made  at  the  time  of  operation. 

Actinomycosis  of  the  Abdominal  Wall. — Actinomycosis  of  the  abdominal 
wall  is  always  secondary  to  actinomycosis  of  the  gut,  usually  of  the  cecum. 
The  infection  becomes  superficial  in  the  right  iliac  fossa  in  most  cases,  less 
commonly  in  the  umbilical  region.  If  an  intestinal  tumor  and  intestinal 
symptoms  have  preceded  the  invasion  of  the  abdominal  wall,  the  diagnosis 
may  be  simple ;  if  not,  it  will  be  difficult.  A  firm,  indurated  area,  usually  of 
small  size,  will  be  palpable  in  the  abdominal  wall,  not  sharply  circumscribed, 
covered  by  normal  skin.  The  progress  of  the  disease  is  usually  slow  and 
chronic,  unless  a  considerable  hole  forms  in  the  intestine,  when  a  phlegmonous 
inflammation,  with  septic  symptoms,  may  result  from  the  escape  of  intestinal 
contents.  Ordinarily  the  skin  is  slowly  involved,  becomes  reddened,  and  finally 
perforated  with  the  discharge  of  pus  usually  having  a  fecal  odor  and  con- 
taining actinomycosis  granules.  In  some  cases  the  granules  will  only  be  recog- 
nized in  the  granulation  tissue  lining  the  sinuses. 

Tumors  of  the  Abdominal  Wall. — Fibroma. — The  abdominal  wall  may  be 
the  seat  of  fibroma  molluscum.  Soft  fibroma,  either  as  an  isolated  growth 
or  in  conjunction  with  disseminated  tumors  of  like  character.     (See  Fibroma.) 

Dermoid  Tumors  of  the  Abdominal  Wall. — Deep-seated  fibromata  having 
certain  interesting  characters  may  arise  from  the  tendinous  and  fascial  layers 
of  the  abdominal  wall.  Histologically  they  may  be  pure  fibromata,  or  occa- 
sionally combined  with  myxoma,  sometimes  with  the  formation  of  cystic  cav- 
ities. These  tumors  occur  for  the  most  part  in  women  between  twenty-five 
and  thirty  years  of  .age,  and  may  appear  after  labor.  They  are  rare  in  men. 
They  have  followed  trauma  to  the  abdomen  in  certain  cases.  They  appear 
in  the  sheath  of  the  recti  muscles;  less  often  in  the  oblique  or  transverse 
muscles  of  the  abdomen.  They  may  grow  outwardly  toward  the  surface  or 
remain  behind  the  muscular  wall  of  the  belly.  They  are  tumors  of  moderately 
rapid  growth,  and  may  reach  a  large  size  in  two  or  three  years.  They  are 
hard,  firm  tumors,  of  smooth  or  coarsely  knobby  surface,  firmly  attached  to 
the  surrounding  tissues,  sometimes  painful,  but  not  tender.     After  the  tumor 


DISEASES    OF   THE   ABDOMINAL  WALL 


699 


attains  some  size  the  sub- 
cutaneous veins  may  be 
dilated.  Mechanical  irri- 
tation may  lead  to  super- 
ficial ulceration,  infection, 
and  sepsis.  When  the  tu- 
mor is  superficial  the  differ- 
ential diagnosis  lies  between 
fibroma  and  sarcoma.  The 
fibromata  usually  merely 
displace  the  surrounding 
tissues,  and  do  not  infil- 
trate them.  When  the  fibro- 
ma is  deeply  seated  it  may 
be  mistaken  for  an  intra- 
abdominal growth,  or  for  an 
intra-abdominal  malignant 
growth  which  has  invaded 
the  abdominal  wall.  There 
will  be  flatness  on  percus- 
sion over  the  tumor,  absence 
of  symptoms  pointing  to  a 
serious  lesion  of  the  intes- 
tine or  other  organ.  Bi- 
manual examination  will 
exclude  fibroma   of  the  uterus 


Fig.  254. — Sarcoma  of  the  Abdominal  Wall.  The  tumor 
was  removed  and  found  to  invade  the  entire  thickness  of 
the  abdominal  wall.  The  patient  was  an  old  and  feeble 
woman.  Death  from  shock.  (Service  of  Dr.  Charles  Mc- 
Burney,  Bellevue  Hospital.) 


The  tumor  will  not  move  with  respiration 
except  to  take  part  in  the  move- 
ments of  the  abdominal  Avail. 
The  cachexia  and  ascites  com- 
mon in  malignant  new  growths 
of  the  abdomen  will  be  want- 
ing. From  sarcoma  of  the 
abdominal  wall  the  diagnosis 
is  impossible  without  the  aid 
of  the  microscope. 

Sarcoma.— Sarcoma  of  the 
abdominal  wall  is  rather  un- 
common. The  tumor  may  orig- 
inate in  a  fibroma  or  in  a  pig- 
mented nevus  or  mole ;  in  the 
latter  case  melano-sarcoma  is 
usually  the  type  found,  or  sar- 
comata may  originate  in  or  be- 

Fig.  255. — Mixed-celled  Sarcoma  of  the  Abdominal  .  TT 

Wall.    (Author's  collection.)    See  text.  neath  the  skin  ae  no  vo.     Here, 


700  THE   ABDOMEN 

as  elsewhere,  the  disease  varies  in  malignancy,  and  possesses  the  usual  history 
and  characters.  The  muscles  of  the  abdominal  wall  are  often  invaded  early, 
but  the  peritoneum  is  usually  spared  until  late  in  the  disease.  Ulceration, 
bleeding,  sloughing,  and  metastasis  regularly  take  place.  The  prognosis  is 
generally  unfavorable.  The  illustration  shows  a  mixed-celled  sarcoma  of  the 
abdominal  wall  of  a  woman  aged  thirty-two.  The  entire  thickness  of  the 
abdominal  wall  was  invaded,  except  the  peritoneum.  The  tumor  had  been 
growing  three  years.  After  I  removed  it  the  woman  remained  well  for  two 
years.     Local  recurrence  then  took  place,  from  which  she  died. 

Lipoma. — Lipoma  may  occur  in  any  of  the  layers  of  the  abdominal  wall, 
chiefly  in  the  subcutaneous  and  in  the  preperitoneal  fatty  tissues.  The  subcu- 
taneous lipomata  occur  rather  at  the  sides  than  in  the  middle  of  the  abdomen. 
They  are  slow-growing,  usually  sessile,  rarely  pedunculated  tumors,  and  may 
attain  a  large  size  in  the  course  of  years.  Their  characters  are  those  of  lipoma 
elsewhere.  (See  Tumors.)  Diffuse  lipoma  may  also  occur.  The  subserous 
lipomata  are  quite  peculiar  tumors.  They  occur  in  the  middle  line  of  the 
belly,  above  the  umbilicus,  and  are  usually  quite  small.  They  perforate  the 
linea  alba,  and  appear  as  small  masses  of  fat  in  the  middle  line  beneath 
the  skin.  Often  they  drag  a  small  process  of  peritoneum  after  them,  creating 
thus  a  small  peritoneal  sac.  They  are  sometimes  wholly  or  partly  reducible 
through  the  hole  in  the  fascia.  There  are  sometimes  digestive  disturbances, 
nausea  and  vomiting  and  abdominal  pain,  accompanying  these  tumors.  The 
differential  diagnosis  between  them  and  a  small  hernia  containing  adherent 
omentum,  or  a  small,  empty  hernial  sac  covered  by  a  layer  of  subserous  fat, 
is  often  impossible  except  by  operation.  When  the  patient  has  a  thick  pan- 
niculus  adiposus,  the  difficulty  is  greatest.  Upon  pushing  these  fatty  tumors 
back  through  the  hole  in  the  fascia,  the  pain  and  digestive  troubles  often 
disappear  at  once. 

Epithelial  Growths  of  the  Abdominal  Wall. — Epithelial  tumors  of 
the  abdominal  wall  are  infrequent.  Papillomata  and  sebaceous  cysts  may 
occur.  (See  Tumors.)  Epithelioma  may  develop  in  scars  or  from  chronic- 
irritation  of  the  skin,  possibly  from  an  X-ray  burn  of  considerable  depth. 
Secondary  carcinomata  of  the  inguinal  glands  are  common  following  carcinoma 
of  the  uterus,  rectum,  penis,  scrotum,  and  lower  extremities.  It  has  rarely 
happened  that  a  carcinoma  of  the  stomach  or  intestine  has  become  adherent 
to,  and  finally  perforated,  the  abdominal  wall.  The  recognition  of  all  these 
conditions  is  not  difficult,  having  in  mind  the  history  of  or  actual  presence  of 
the  primary  growth. 

Echinococcus  of  the  Abdominal  Wall. — Echinococcus  of  the  abdominal  wall 
is  one  of  the  rarest  localizations  of  this  disease,  only  a  very  few  such  cases 
having  been  observed.  The  cysts  may  be  located  in  the  lumbar  or  umbilical 
regions  or  elsewhere.  A  differential  diagnosis  from  echinococcus  of  an  intra- 
abdominal origin  may  be  difficult,  since  if  the  cyst  originate  behind  the  mus- 
cular wall  of  the  belly,  it  will  grow  into  the  abdominal  cavity  and  form  adhe- 


DISEASES   OF   THE   UMBILICUS  701 

sions  to  the  viscera.  The  disease  is  slow  and  insidious  in  its  progress.  The 
patients  suffer  from  abdominal  pain,  disturbances  of  digestion  and  nutrition. 
Pressure  symptoms  upon  the  diaphragm  causing  dyspnea  are  absent,  thus  serv- 
ing to  exclude  echinococcus  of  the  liver.  If  pus  infection  takes  place,  the 
symptoms  of  sepsis  are  added.  The  abdominal  wall  may  be  perforated  with 
evacuation  of  the  sac.  When  the  signs  are  such  that  an  intra-abdominal  origin 
cannot  be  excluded,  it  will  be  unwise  to  use  an  aspirating  needle  for  diagnostic 
puncture,  since  the  peritoneal  cavity  mjght  thus  be  infected  by  the  escape  of 
the  contents  of  the  cyst.      (See  Echinococcus.) 

DISEASES   OF   THE   UMBILICUS 

Congenital  Anomalies  of  the  Umbilicus. — Imperfect  closure  or  failure  to 
close  of  the  omphalomesenteric  duct — normally  closed  at  the  end  of  the  eighth 
week  of  fetal  life— may  cause  congenital  anomalies  of  the  umbilicus.  A  num- 
ber of  different  conditions  may  exist. 

1.  The  communication  with  the  small  gut  may  remain  patent  from  the 
intestine  through  the  umbilicus  and  into  the  cord  (omphalomesenteric  fistula). 

2.  The  duct  may  be  closed  up  to  the  umbilicus,  but  patent  outside  the  abdo- 
men (umbilical  omphalomesenteric  diverticulum). 

3.  The  duct  may  be  closed  from  the  intestine,  and  also  at  the  umbilicus, 
but  patent  between  these  points  (omphalomesenteric  cyst). 

4.  The  connection  between  the  duct  and  the  umbilicus  is  not  present,  but 
the  communication  with  the  intestine  remains  open,  forming  an  intestinal 
diverticulum  of  variable  size  and  length,  situated  from  a  foot  to  twenty  inches 
from  the  ileo-cecal  valve  (Meckel's  diverticulum).  The  most  common  anomaly 
of  the  four,  found  in  about  one  individual  among  fifty.  (See  Meckel's  Diver- 
ticulum.) 

1.  Omphalomesenteric  Fistula. — When  the  duct  is  patent  throughout, 
separation  of  the  cord  after  birth  will  leave  behind  a  fistulous  orifice  lined 
by  mucous  membrane,  which  discharges  mucus  or  mucus  and  intestinal  con- 
tents. The  former  variety  is  to  be  differentiated  from  the  much  rarer  congen- 
ital fistula?  of  the  stomach  by  the  fact  that  the  latter  furnish  an  acid  secretion 
which  may  digest  the  surrounding  skin.  In  another  rare  form  the  intra- 
abdominal pressure  causes  a  protrusion  of  the  mucous  membrane  of  the  duct ; 
this  prolapse  may  increase,  dragging  the  intestine  after  it  until  the  latter 
leaves  the  abdomen  and  lies  as  an  everted  loop  upon  the  belly.  There  will 
then  be  found  two  orifices,  both  leading  into  the  intestine.  A  congenital 
umbilical  anus  exists.  If  the  umbilical  ring  is  small,  such  children  may  die 
of  intestinal  obstruction.  A  careless  ligation  of  the  cord  in  the  presence  of 
a  congenital  umbilical  hernia  containing  intestine  may  wound  or  divide  the 
gut.  Careful  palpation  of  the  cord,  should  it  seem  thicker  than  normal,  should 
detect  the  presence  of  intestine  from  the  characteristic  gurgling  and  reduci- 
bility. 


702  THE   ABDOMEN 

2.  Omphalomesenteric  Diverticulum. — In  this  form,  after  the  sepa- 
ration of  the  cord,  a  small,  red,  moist  tumor  remains  behind,  covered  by 
mucous  membrane ;  this  may  reach  the  size  of  a  raspberry,  which  it  somewhat 
resembles  in  appearance.  The  mucous  membrane  passes  off  the  surface  of  the 
tumor  into  the  normal  skin  of  the  abdomen.  Xo  fistulous  opening  through 
the  umbilicus  into  the  intestine  exists,  thus  differentiating  the  condition  from 
omphalomesenteric  fistula  in  which  a  probe  can  be  passed  through  the  fistulous 
tract  into  the  gut. 

3.  The  omphalomesenteric  cysts  are  so  rare  that  their  description  is  here 
omitted. 

4.  See  Meckel's  diverticulum. 

Congenital  Anomalies  of  the  Urachus. — The  fetal  tube  connecting  the  urinary 
bladder  with  the  allantois  may  remain  patent  at  birth:  (1)  From  the  bladder 
to  the  umbilical  cord.  (Congenital  urachus  fistula.)  (2)  The  urachus  may 
communicate  with  the  bladder  and  remain  open  a  variable  distance  in  the 
abdomen,  but  the  opening  does  not  extend  to  the  umbilicus.  An  umbilical 
urinary  fistula  may  develop  during  infancy  or  later  in  life.  (3)  The  ura- 
chus is  closed  off  from  the  bladder  and  at  the  umbilicus,  but  remains  patent 
between  these  points.  A  urachus  cyst  may  develop  in  later  years  between 
the  bladder  and  the  abdominal  wall — a  rare  condition.  The  etiological 
relation,  however,  between  such  cysts  and  the  urachus  is  denied  by  some 
observers. 

1.  In  the  first  variety,  after  the  cord  separates,  a  fistulous  tract  is  present, 
lined  by  mucous  membrane  from  which  urine  escapes,  continuously  or  intermit- 
tently, in  larger  or  smaller  quantity.  Commonly  a  prolapse  of  the  wall  of 
the  urachus  occurs,  forming  a  considerable  projection  from  the  navel,  of  cylin- 
drical shape;  the  urachus  opens  at  its  tip.  If  the  umbilical  ring  is  large  the 
bladder  may  prolapse,  and  much  or  all  of  the  urine  may  escape  through  the 
umbilicus.  Before  closing  the  opening  the  surgeon  should  look  for  obstruc- 
tion to  the  outflow  of  urine  through  the  normal  channels,  phimosis,  or  a  nar- 
row meatus  urinarius.  If  infection  of  the  urachus  takes  place  the  discharge 
may  be  purulent  and  ammoniacal. 

2.  The  second  variety  rarely  if  ever  gives  rise  to  symptoms  unless  infec- 
tion occurs,  usually  through  the  bladder.  The  trouble  may  arise  during  child- 
hood or  adult  life.  An  inflammatory  tumor  will  then  be  formed  behind  the 
pubes.  There  will  usually  be  purulent  urine  and  symptoms  of  cystitis.  The 
tumor  may  rupture  externally,  or  an  incision  will  enter  a  cavity  above  and 
in  front  of  the  bladder  containing  a  mixture  of  urine  and  pus.  Occasionally 
a  calculus  has  been  removed  from  such  a  cavity. 

■>.  Although  the  above  conditions  are  rare,  the  third  variety,  "  urachus 
cysts,"  is  still  more  rare.  They  present  as  noninflammatory  tumors  in  the 
suprapubic  region,  giving  the  physical  signs  of  a  cyst — dullness  on  percussion 
and  elasticity  on  palpation.  The  diagnosis  can  be  made  from  the  character  of 
the  epithelium  lining  the  cyst  wall. 


DISEASES    OF   THE   UMBILICUS  703 

Inflammatory  Processes  of  the  Umbilicus  in  Infants  and  Adults. — After  the 
separation  of  the  cord  the  stump  may  become  the  seat  of  a  small  granuloma. 
The  characteristic  appearances  of  granulation  tissue  covered  by  a  purulent 
discharge,  and  the  generally  pedunculated  shape  of  the  growth,  together  with 
absence  of  the  signs  of  fistula,  render  the  diagnosis  easy. 

Infection  of  the  Umbilicus. — Infection  of  the  umbilicus  among  infants  and 
among  children  may  occur  in  a  variety  of  forms.  Diphtheria,  tetanus,  pyogenic 
cellulitis,  noma,  phlegmonous  inflammation  of  the  abdominal  wall,  septic  phle- 
bitis, leading  to  thrombosis  and  secondary  abscesses  in  the  liver,  or  pyemia,  peri- 
tonitis, are  all  observed,  usually  as  the  result  of  uncleanliness  and  depressed 
states  of  vitality.  These  conditions  give  rise  to  signs  and  symptoms,  fully 
discussed  under  appropriate  headings.  Among  adults  inflammations  of  the 
umbilicus  occur  for  the  most  part  among  those  who  do  not  bathe,  and  who  are 
obese  or  have  a  deep  umbilicus.  Intertrigo  and  eczema  are  observed  among 
fat  women  in  this  region.  In  rare  cases  where  the  umbilicus  is  very  deep 
and  the  external  skin  orifice  is  narrow,  neglect  of  cleanliness  may  be  followed 
by  retention  and  decomposition  of  the  sebaceous  and  other  secretions  of  the 
skin.  The  umbilicus  becomes  swollen,  red,  and  tender,  a  stinking,  smeary 
discharge  escapes  from  the  umbilical  ring,  and  a  considerable  quantity  of  foul- 
smelling  sebaceous  matter  may  be  removed  from  the  cavity  with  a  scoop. 

Perforations  of  the  Umbilicus  in  Adults. — A  great  variety  of  inflammatory 
conditions  of  the  abdomen  may  perforate  the  umbilicus,  and  discharge  pus  or 
other  material,  often  leaving  a  fistula  behind.  Among  these  conditions  may 
be  mentioned  traumatic  and  inflammatory  ruptures  of  the  bladder ;  a  urinary 
fistula  is  then  formed.  Cholecystitis  may  form  an  abscess  pointing  at  the 
navel  with  the  discharge  of  pus,  gall-stones,  and  bile.  Perforations  of  the  intes- 
tine from  many  causes  may  discharge  at  this  point.  Such  may  be  gangrenous 
perforation  of  a  strangulated  umbilical  hernia,  a  strangulated  or  perforated 
Meckel's  diverticulum,  an  abscess  arising  from  the  vermiform  appendix,  a 
typhoid  perforation,  and  perforation  from  a  foreign  body  in  the  stomach  or 
intestine.  Through  such  perforations  intestinal  or  stomach  contents  will  be 
discharged,  together  with  pus,  a  foreign  body,  occasionally  round-  or  tape-worms. 
I  recently  operated  upon  a  woman  who  had  had  an  intestinal  fistula  at  the 
umbilicus  for  eight  years.  The  fistula  followed  some  illness  the  nature  of 
which  was  not  clear.  There  were  two  holes  in  the  small  gut  and  one  in  the 
sigmoid.     The  holes  were  closed  by  suture.     The  patient  was  cured. 

A  malignant  growth  of  the  gut,  an  echinococcus  cyst,  a  tuberculous  perito- 
nitis, an  ovarian  cyst,  or  even  an  ascites  from  any  cause,  may  rupture  at  this 
point.  Usually  the  diagnosis  will  be  plain  from  the  history  of  the  case  and 
the  character  of  the  discharge,  exploration  of  the  fistula  with  a  sound  or  probe, 
and  other  concomitant  signs  and  symptoms  which  point  to  some  definite  causa- 
tion. In  certain  instances  the  source  of  the  fistula  can  be  determined,  more 
or  less  accurately,  by  injecting  colored  fluids  into  the  fistulous  tract  or  into 
the  bladder,  the  rectum,  or  causing  the  patient  to  swallow  such  a  fluid  (methy- 


704  THE    ABDOMEN 

lene-blue  solution,  for  example).  The  subsequent  appearance  of  the  fluid  in 
the  rectum,  stomach,  bladder,  or  at  the  orifice  of  the  fistula,  as  the  case  may  be, 
will  sometimes  afford  valuable  information. 

Tumors  of  the  Umbilicus. — Soft  papillomata  or  papillary  fibromata  may 
occur  in  the  umbilicus  from  chronic  irritation.  The  tumor  has  the  character- 
istic pink  color  and  cauliflower  appearance,  and  an  offensive  thin  discharge  may 
occur  from  the  macerated  surface.  Such  papillomata  may  ulcerate  and  resem- 
ble epithelial  cancer.  The  microscope  must  be  used  for  diagnosis  in  these 
cases.  Sarcoma  of  the  umbilicus  has  been  observed  chiefly  in  women  in  the 
form  of  a  rather  slow-growing  and  not  very  malignant  fibro-sarcoma.  The 
tumor  is  rather  hard,  sessile,  and  may  reach  a  considerable  size  before  the 
patient  suffers  enough  inconvenience  to  make  her  seek  advice.  The  tumor  is 
covered  by  normal  or  bluish  skin,  there  may  be  dilated  veins  upon  its  surface. 
Ulceration  may  occur  from  trauma.  Fibroma,  fibro-lipoma,  myxoma,  and 
angioma  of  the  navel  have  been  observed.  Atheromatous  and  dermoid  cysts 
also  occur. 

Caecixoma. — Both  the  slow  and  rapidly  growing  forms  of  epithelioma  are 
observed  among  elderly  people,  usually  as  the  result  of  chronic  irritation  from 
dirt,  or  upon  a  simple  papilloma  as  a  basis.  The  characteristic  hard,  ulcerated 
surface  with  prominent,  firm  edges  and  other  characters,  as  described  under 
Tumors,  render  the  diagnosis  simple.  Carcinoma  having  cells  resembling  intes- 
tinal glandular  epithelium,  scirrhus,  and  other  forms  of  cancer  are  occasionally 
seen  growing  from  the  umbilicus.  The  characteristic  history  and  signs  of  cancer 
are  present.  Carcinoma  of  the  navel  may  also  occur  secondary  to  cancer  of  the 
stomach,  intestine,  or  uterus,  either  by  direct  extension  or  metastasis.  The  micro- 
scopical characters  of  the  tumor  will  indicate  the  character  of  the  primary 
growth. 


CHAPTER    XXIV 
THE   PERITONEUM 

General  Considerations. — The  peritoneum  lines  the  abdominal  cavity,  form- 
ing by  far  the  largest  serous  sac  in  the  body,  its  surface  being  about  equal  in 
area  to  that  of  the  general  integument.  The  membrane  is  reduplicated  over  the 
surface  of  the  abdominal  and  pelvic  viscera  in  such  a  manner  that  certain 
organs  receive  almost  a  complete  covering  of  peritoneum  (jejunum,  ileum, 
transverse  colon,  stomach)  ;  in  others,  the  covering  is  only  partial  (duodenum, 
cecum,  bladder)  ;  in  still  others,  the  organ  simply  lies  in  contact  with  this 
membrane,  which  passes  smoothly  across  its  surface  (kidney).  The  anatom- 
ical details  are  mentioned,  when  necessary,  under  the  injuries  and  diseases  of 
the  separate  organs.  The  opposed  peritoneal  surfaces  lie  everywhere  in  contact ; 
a  capillary  space  merely  exists  between  them.  The  surface  is  covered  by  flat 
endothelium.  On  the  abdominal  wall,  peritoneum  is  but  loosely  attached  to 
the  surrounding  tissues ;  the  same  is  true  of  the  bladder,  much  of  the  intes- 
tine, and  stomach.  Its  reflection  over  certain  solid  organs — liver  and  spleen — 
is  firmly  adherent  to  the  underlying  connective-tissue  capsule  of  these  viscera. 
In  the  male  the  peritoneum  is  a  closed  sac  (stomata  having  been  described  by 
some  observers  as  existing  in  the  peritoneum  covering  the  diaphragm).  In  the 
female  the  open  ends  of  the  Fallopian  tubes  afford  communication  with  the 
interior  of  the  uterus,  and  infectious  processes  readily  spread  from  the  uterus 
and  tubes  to  the  peritoneum.  Various  physiological  recesses,  folds,  bands,  and 
orifices  exist  in  the  peritoneum,  some  of  which  are  important  in  relation  to 
the  diagnosis  of  hernia  and  intestinal  obstruction,  as  well  as  to  the  spread  and 
accumulation  of  inflammatory  exudates.  They  will  be  mentioned  under  appro- 
priate headings.  The  intimate  relation  of  the  peritoneum  to  the  abdominal 
organs  is  very  important  surgically.  Injuries  of  the  peritoneum  usually  involve 
the  viscera,  and  diseases  of  the  viscera  quite  commonly  extend  to  the  peri- 
toneum ;  indeed,  diseases  beginning  in  the  peritoneum  itself  are  exceedingly 
rare  as  compared  with  those  beginning  in  adjacent  structures  and  extending 
to  the  peritoneum.  When  disease  of  a  septic  character  penetrates  one  of  the 
abdominal  viscera  and  invades  the  peritoneum,  the  clinical  picture  is  quite 
commonly  changed  with  great  suddenness.  The  symptoms  caused  by  inflam- 
mation of  the  peritoneum  entirely  overshadow  in  gravity  and  importance  those 
caused  by  the  original  lesion  of  the  viscus. 

46  705 


706  THE   PERITONEUM 

Sources  of  Infection  of  the  Peritoneum. — Infection  of  the  peritoneum  occurs 
through  wounds  and  inflammations  of  the  abdominal  wall.  Much  more  com- 
monly, through  wounds,  inflammations,  and  perforative  lesions  of  the  alimen- 
tary tract;  of  these,  the  most  frequent  source  is  the  vermiform  appendix. 
Among  other  frequent  sources  are  peptic  ulcers  of  the  stomach  and  duodenum ; 
typhoid  ulcers  of  the  ileum  ;  tuberculous  and  cancerous  ulcerations  of  the  cecum  ; 
tuberculous,  syphilitic,  and  cancerous  ulcerations  of  the  sigmoid  flexure  and 
transverse  colon.  A  foreign  body  in  the  intestine  may  cause  ulceration  and 
perforation.  Distended  bowel  above  the  seat  of  a  stricture  may  be  the  seat 
of  ulceration  and  perforation,  due  to  pressure.  Infection  also  occurs  through 
strangulated  and  partly  or  wholly  gangrenous  coils  of  intestine,  in  cases  of 
strangulated  hernia,  volvulus,  strangulation  by  bands,  intussusception ;  through 
suppurative  or  necrotic  lesions  of  the  glandular  organs  of  the  belly— liver,  bile 
passages,  pancreas,  spleen,  kidney,  and  ureter ;  through  the  tissues  of  the  uterus 
in  septic  infections  of  that  organ  by  way  of  the  lymph  canals ;  through  the 
open  mouths  of  the  Fallopian  tubes,  and  through  infections  of  the  ovary; 
through  infectious  lesions  of  the  bladder,  prostate,  seminal  vesicles,  and  sper- 
matic cord ;  through  lymph  vessels  and  lymph  glands  of  any  of  the  pelvic  or 
abdominal  organs ;  through  infected  thrombi  or  emboli  of  arteries  and  veins 
of  the  abdomen ;  through  inflammatory  processes  of  the  pleura,  vertebra1,  or 
pelvic  bones.  Cases  of  hematogenous  infection  of  the  peritoneum  with  pyo- 
genic microbes — i.  e.,  cases  of  so-called  idiopathic  peritonitis,  with  no  discov- 
erable lesion  which  might  account  for  the  infection,  are  so  rare  that  their 
existence  is  doubtful. 

Bacteria  Causing  Peritonitis. — Streptococcus  pyogenes  is  the  most  frequent 
as  well  as  the  most  dangerous  invader  of  the  peritoneum ;  staphylococcus  is  less 
common.  The  saprophytes  of  the  intestine  (Bacillus  coli  communis)  are  regu- 
larly present  in  perforative  lesions  of  the  alimentary  tract.  The  growth  of 
this  form  is  so  vigorous  that  other  bacteria  may  disappear,  so  that,  when 
at  the  time  of  operation  a  culture  is  taken  from  the  exudate,  bacillus  coli 
may  be  the  only  germ  found,  the  original  infection  having  been  caused  per- 
haps by  streptococcus  or  some  other  organism.  Among  other  bacteria  found 
in  cases  of  peritonitis  are  the  pneumococcus,  Bacillus  typhosus,  and  the 
gonococcus. 

Infection  with  tubercle  bacilli  may  occur  as  a  part  of  a  general  tuberculosis 
or  as  a  localized  process.  (See  Tuberculous  Peritonitis.)  Apparently  hemat- 
ogenous infection  of  the  peritoneum  with  pneumococcus  occasionally  occurs 
as  a  complication  of  pneumonia.  Peritonitis  is  occasionally  observed  in  acute 
articular  rheumatism,  probably  a  septic  disease. 

Behavior  of  the  Peritoneum  when  Exposed  to  Infection  and  Trauma. — The 
surface  of  the  peritoneum  is  very  large,  its  absorbing  power  is  very  great,  and 
fluids  are  taken  up  from  its  surface  with  extraordinary  rapidity.  The  repara- 
tive power  of  the  peritoneum  exceeds  that  of  any  other  structure,  and  repair 
is   very   rapid.      These   facts  have   a  bearing  upon   the   course   of  peritoneal 


THE   PERITONEUM    WHEN   EXPOSED   TO    INFECTION  707 

injuries  and  infections.  When  exposed  to  septic  irritation  the  peritoneum 
reacts  speedily,  throwing  <>ni  an  abundant  exudate  of  serum,  fibrin,  or  pus, 
or  a  combination  of  these  ingredients.  The  fibrous  exudate  is  often  abundant 
and  serves  to  cause  agglutination  between  opposed    peritonea]   surfaces,   thus 

limiting  the  spread  of  infection  more  or  less  completely.  It  has  been  demon- 
strated that  the  normal  peritoneum  is  capable  of  absorbing,  and  thus  dispos- 
ing of  considerable  quantities  of  bacteria  and  their  toxins  without  any  inflam- 
matory reaction.  If  the  peritoneum  is  wounded,  bruised,  or  unduly  irritated, 
mechanically  or  chemically,  as  by  rough  handling  or  the  action  of  chemical 
antiseptics,  or  if  foreign  bodies  are  present,  such  as  masses  of  blood,  frag- 
ments of  contused  or  dead  tissue,  masses  of  fibrin,  a  piece  of  gauze,  etc.,  thus 
constituting  a  dead  space,  in  which  bacteria  may  flourish,  this  power  of 
absorbing  and  destroying  the  bacteria  is  lost  or  decidedly  impaired.  Infec- 
tion and  inflammation  of  the  peritoneum  follow.  The  character  and  course 
of  the  inflammation  varies  widely  in  different  eases,  being  modified  by  fac- 
tors, some  of  which  we  shall  presently  discuss.  It  will  be  convenient  for 
purposes  of  classification  to  divide  peritonitis  into  several  generally  recog- 
nized types : 

I.  Peritonitis  caused  by  pyogenic  and  saprophytic  germs. 

1.  Peritoneal  sepsis;  diffuse  septic  peritonitis. 

2.  Progressive  purulent  peritonitis,  with  putrid  decomposition. 

3.  Progressive  fibrino-purulent  peritonitis. 

4.  Localized  peritonitis. 

5.  Chronic  peritonitis:  (a)  empyema  of  the  peritoneum;  (7>)  chronic  adhe- 
sive peritonitis. 

II.  Aseptic  peritonitis. 

III.  Tuberculous  peritonitis. 

The  severer  forms  of  peritonitis  are  distinguished  by  their  progress  ire 
character  and  by  the  pronounced  septic  symptoms  accompanying  them.  The 
process  tends  to  advance  and  to  involve  a  large  extent  of  peritoneum — i.  e.,  to 
become  diffuse  or  general,  and  rapidly  to  destroy  life  by  septic  absorption  and 
by  producing  intestinal  paralysis.  The  several  types  can  be  differentiated 
clinically  from  the  localized  form  in  wdiich  a  small  or  moderate  area  of  the 
peritoneum  only  is  inflamed,  the  spread  of  the  process  being  prevented  by  firm 
adhesions.  It  is  to  be  borne  in  mind  that  a  process  at  first  distinctly  localized 
may  suddenly  or  gradually  become  diffuse.  The  fibrinous  barriers  may  be 
invaded  by  pyogenic  germs  and  liquefied,  permitting  a  sudden  or  gradual  spread 
of  septic  material  into  the  noninfected  portion  of  peritoneum.  It  is  not  always 
possible  to  distinguish  the  more  severe  types  one  from  the  other.  Indeed,  one 
may  find,  upon  opening  the  abdomen,  that  several  processes  coexist.  In  one 
part  of  the  belly  a  localized  abscess  filled  with  stinking  pus,  and  shut  off  by 
adhesions ;  in  another,  a  diffuse  and  spreading  fibrino-purulent  exudate :  in  a 
third,  a  cloudy  serous  effusion  containing  red  and  white  blood  cells :  in  a  fourth, 
fibrin  alone  in  thick  flakes  and  masses;  in  a  fifth,  slightly  cloudy  serum,  which 


708  THE   PERITONEUM 

may  be  sterile.  The  inflamed  coils  of  gut  have  lost  their  luster ;  they  are  deep 
red,  swollen,  and  edematous,  coated  here  and  there  with  flakes  of  fibrin ;  usu- 
ally distended,  and  temporarily  or  permanently  paralyzed. 

The  character  and  course  of  the  inflammation  in  the  given  case  depends 
upon  a  number  of  conditions.  Sudden  perforations  or  ruptures  of  the  ali- 
mentary canal,  or  sudden  pouring  out  of  septic  material,  from  a  gangrenous 
or  purulent  focus,  so  that  a  large  dose  of  virulent  bacteria  and  their  toxins 
is  thrown  at  once  into  the  peritoneal  space,  is  usually  followed  by  an  intense 
and  rapidly  progressive  peritonitis,  or  by  an  acute  septic  intoxication,  result- 
ing in  collapse  and  death,  before  much  inflammatory  reaction  has  occurred. 
In  the  latter  ease  the  amount  of  exudate  is  small,  of  thin  sero-purulent  or 
bloody  character,  sometimes  brown  in  color,  and  putrid.  No  adhesions  are 
formed,  and  the  septic  material  is  freely  and  rapidly  diffused  throughout  the 
abdominal  cavity.  The  peritoneum  is  dull  but  not  notably  swollen  nor  reddened. 
Scattered  flakes  of  fibrin  may  be  present.  The  patient  is  suddenly  seized  with 
an  excruciating  pain  in  the  abdomen ;  sometimes  general ;  sometimes  referred  to 
the  umbilicus ;  sometimes  to  the  seat  of  the  perforation.  The  belly  is  flat  or  re- 
tracted (the  scaphoid  abdomen)  ;  the  muscles  of  the  abdominal  wall  are  of  board- 
like hardness;  general  abdominal  tenderness  is  present.  The  temperature  may 
be  elevated,  normal,  or  subnormal.  The  pulse  is  rapid,  feeble,  and  compressible. 
The  face  is  pinched.  The  extremities  are  cold.  Repeated  vomiting  occurs.  The 
patient  passes  into  a  condition  of  collapse,  from  which  he  does  not  rally,  and  dies 
within,  perhaps,  twenty-four  hours  or  less,  from  the  time  of  general  invasion 
of  the  peritoneum.  This  type  of  the  disease  is  commonly  called  "  peritoneal 
sepsis."  It  is  seen  more  often  from  the  sudden  rupture  of  a  gangrenous  appen- 
dix than  from  any  other  cause.  The  symptoms  are  due  to  septic  absorption 
rather  than  to  the  inflammation  of  the  peritoneum. 

Recent  experiments  performed  on  rabbits  in  the  pathological  laboratory  of 
the  Cornell  University  Medical  College  are  interesting  in  this  connection :  It 
was  found  that  after  the  injection  of  pure  cultures  of  virulent  pyogenic  microbes 
into  the  peritoneal  cavity,  blood  cultures,  taken  five  minutes  after  the  injec- 
tion had  been  made,  showed  the  micro-organisms  present  in  abundance  in  the 
circulating  blood.  Thus  it  may  well  be  that  the  condition  we  have  been  accus- 
tomed to  regard  as  due  to  the  absorption  of  bacterial  toxins  from  the  perito- 
neum is,  in  fact,,  a  true  septicemia. 

It  has  been  found  that  during  starvation  the  bacterial  flora  of  the  intestine 
are  diminished  in  number.  Moreover,  the  bacteria  are  less  numerous  in  the 
upper  than  in  the  lower  portion  of  the  intestine.  Perforation  lesions,  then, 
which  occur  when  the  intestine  is  nearly  empty,  and  lesions  which  occur  in  the 
upper  part  of  the  small  intestine  and  stomach,  might  be  expected  to  produce 
a  somewhat  less  violent  peritonitis  than  when  the  intestine  was  full  and  the 
lesion  low  down.  Experience  shows  that,  in  some  cases,  at  least,  this  expecta- 
tion is  realized  to  this  extent,  that  such  perforations,  when  followed  by  exten- 
sive extravasation  of  the  contents  of  the  stomach  or  duodenum,  are  not  attended 


PEKITONITIS  709 

by  profound  septic  symptoms  nor  by  intense  inflammation  of  the  peritoneum 
for  several  hours. 

Progressive  Purulent  Peritonitis  with  Putrid  Decomposition  of  the  Exu- 
date.— Progressive  purulent  peritonitis  with  putrid  decomposition  of  the  exudate 
occurs  when  saprophytes  are  associated  with  the  pyogenic  cocci.  Stinking  gases 
may  be  formed  in  the  exudate.  The  most  intense  and  violent  cases  of  perito- 
nitis are  caused,  as  a  rule,  by  the  streptococcus.  The  staphylococcus  appears 
to  be  less  virulent.  Cases  in  which  bacillus  coli  alone  are  found  are,  in 
my  experience,  attended  by  an  abundant  exudate,  but  not  the  most  violent 
sepsis.  The  pneumococcus  is  also  not  very  virulent.  Cases  of  gonorrheal 
peritonitis  usually  remain  localized  in  the  lower  part  of  the  abdomen,  but 
not  always. 

If  perforation,  or  invasion  of  the  peritoneum  takes  place,  not  suddenly  but 
slowly,  a  plastic  exudate  of  fibrin  will  be  thrown  out  from  the  inflamed  serous 
surface  and  adhesions  formed,  such  that  the  spread  of  septic  material  in  the 
belly  is  delayed  or  prevented.  If  such  adhesions  are  inadequate  the  septic 
process  spreads,  slowly  or  rapidly,  involving  one  area  after  another,  so  that 
communicating  or  apparently  separate  loculi — containing  pus  more  or  less  com- 
pletely walled  off  by  fibrinous  adhesions — are  formed  in  different  portions  of 
the  belly.  Marked  distention  of  the  abdomen  is  often  present  in  these  cases. 
The  amount  of  exudate  is  commonly  large  (progressive  fibrino-purulent  perito- 
nitis). The  spread  of  the  infection  tends  to  follow  certain  fairly  definite 
routes — for  example,  infection  beginning  in  the  right  iliac  fossa  tends  to 
follow  the  outer  surface  of  the  ascending  colon  to  the  under  surface  of  the 
liver.  To  follow  the  anterior  surface  of  the  ascending  colon,  and  infect  the 
under  surface  of  the  diaphragm  and  the  upper  surface  of  the  liver.  To  travel 
downward  to  the  true  pelvis,  thence  to  follow  the  rectum  and  sigmoid  flexure 
upward  in  the  direction  of  the  spleen.  The  mesentery  of  the  small  intestine 
acts,  to  some  extent,  as  a  barrier  to  the  direct  crossing  of  the  abdomen.  Adhe- 
sions between  the  omentum  and  the  abdominal  wall  may  prevent  the  infection 
of  the  transverse  colon  and  the  stomach.  In  the  same  way  the  omentum  may 
protect  the  small  intestine  when  the  infection  has  proceeded  from  the  upper 
part  of  the  belly. 

In  some  of  the  cases  of  progressive  purulent  peritonitis  the  patient  is  not 
seen  until  the  process  has  become  fairly  generalized.  Such  a  condition  may 
follow  a  blow  or  kick  upon  the  abdominal  wall — for  example,  with  rupture  of 
the  intestine  and  the  escape  of  intestinal  contents,  in  quantity,  into  the  peri- 
toneal cavity.  Suppose  the  patient  to  have  survived  for  twenty-four  hours. 
He  will  be  found  with  a  rigid  and  distended  belly.  The  general  symptoms  arc 
those  of  profound  sepsis.  Upon  opening  the  abdomen,  a  gush  of  material 
resembling  pea  soup  escapes  under  tension.  The  exudate  consists  of  rather 
thin  pus,  mixed  with  flakes  of  fibrin  and  intestinal  contents.  A  foul  odor  and 
gas  may  or  may  not  be  present.  The  intestinal  coils  are  everywhere  distended. 
The  peritoneum  is  dull,  coated  with  flakes  of  fibrin,  in  some  places  reddened, 


710  THE   PERITONEUM 

edematous,  and  swollen.  There  are  no  separate  loculi  of  pus ;  the  exudate  is 
found  free  in  all  accessible  portions  of  the  abdomen. 

General  and  Local  Symptoms  of  Diffuse  Purulent  Peritonitis, 
Considered  in  Detail. — All  the  forms  of  diffuse  purulent  peritonitis,  from 
whatever  cause,  present  a  similar  clinical  picture.  In  some,  and  those  the 
most  rapidly  fatal,  the  symptoms  of  septic  intoxication  predominate ;  the  local 
lesions  and  symptoms  do  not  have  time  to  develop  fully  before  death  occurs 
(peritoneal  sepsis).  In  others  a  slowly  or  rapidly  spreading  local  lesion  pro- 
duces marked  local  signs  and  symptoms,  and,  in  some  cases,  such  a  lesion  is 
associated,  for  a  time  at  least,  with  only  moderate  symptoms  of  septic  intoxica- 
tion (progressive  fibrino-purulent  peritonitis). 

Some  cases  of  diffuse  peritonitis  will  have  been  preceded  by  a  localized  peri- 
tonitis from  an  acute  suppurative  appendicitis,  for  example.  In  others,  dis- 
turbances of  function  of  some  special  organ  will  be  followed  by  perforation 
(ulcer  of  the  stomach).  In  others,  a  general  disease  will  exist  (typhoid  fever). 
In  still  others,  the  attack  may  suddenly  appear  in  an  individual  apparently 
in  good  health  (ulcer  of  the  duodenum).  Upon  the  advent  of  peritonitis  defi- 
nite symptoms  appear  at  once.  The  constant  symptoms  are  abdominal  pain 
and  vomiting.  The  distinctive  signs  are  tenderness  and  rigidity  of  the  abdom- 
inal wall.  Frequently  accompanying  the  onset  of  abdominal  pain  there  is 
vomiting,  occasionally  chilly  sensations,  rarely  a  chill.  The  patient  looks  ill 
at  once.  He  can  scarcely  stand  upright,  and  lies  down  on  his  back  as  soon  as 
may  be.  The  expression  of  the  face  is  disturbed,  anxious,  and,  at  first,  often 
flushed ;  later,  as  the  disease  progresses,  the  features  become  pinched  and  drawn ; 
as  death  approaches  there  is  cyanosis.  In  order  to  diminish  the  tension  of  the 
abdominal  muscles,  the  patient  lies  on  his  back  with  his  knees  and  thighs  flexed. 
He  makes  no  movement  which  will  disturb  the  abdomen,  but,  being  in  pain  and 
restless,  he  may  move  his  hands  and  arms  frequently.  He  breathes  as  quietly 
as  he  may,  the  respirations  are  superficial  and  increased  in  frequency.  Later, 
when  the  distended  intestines  push  the  diaphragm  upward,  breathing  is  still 
more  distinctly  thoracic,  superficial,  and  rapid ;  sometimes  gasping  as  the  dis- 
ease becomes  far  advanced.  The  voice  is  weak,  and  may  be  hoarse.  In  bad 
cases  the  tongue  is  coated,  dry,  and  brown ;  sordes  may  be  present  on  the  lips 
and  teeth. 

Pulse. — In  cases  of  peritoneal  sepsis  the  pulse  is  that  of  shock,  not  neces- 
sarily very  rapid,  but  weak,  thready,  and  compressible.  In  cases  of  ordinary 
progressive  peritonitis  the  pulse  shows  a  continual  increase  in  rapidity  as  well 
as  a  peculiar  want  of  volume  and  tension.  The  pulse  during  the  earlier  stages 
of  the  disease  may  be  110  to  120  or  more  beats  a  minute.  The  sensation  given 
to  the  finger  is  that  the  pulse  wave  is  small.  As  death  approaches  the  pulso 
becomes  too  rapid  to  count. 

Temperature. — There  is  nothing  characteristic  about  the  temperature  of 
peritonitis.  In  the  worst,  cases,  following  the  sudden  flooding  of  the  system 
with  septic  material,  a  subnormal  temperature  is  the  rule,     if  the  patient  sur- 


PERITONITIS  711 

vives  for  a  day,  an  ordinary  temperature  curve  of  septicemia  may  be  noted, 
up  and  down  at  irregular  intervals.  In  cases  of  progressive  peritonitis  a  mod- 
erate or  considerable  rise  of  temperature,  such  as  is  seen  in  any  septic  condition, 
is  observed.  The  important  point  to  bear  in  mind  is  that  the  height  of  the 
temperature  bears  no  necessary  relation  to  the  gravity  of  the  disease,  except 
that  a  subnormal  temperature  is  a  bad  omen.  Often  the  temperature  remains 
fairly  low  while  the  pulse  grows  more  and  more  rapid. 

Cerebration. — In  some  of  the  rapidly  fatal  cases  the  patient  may  be  rather 
dull  from  the  beginning;  the  benumbing  effect  of  septic  poisoning  may  cause 
him  to  feel  but  little  pain.  He  will,  however,  look  ill.  Rigidity  of  the  abdo- 
men will  be  present.  Ordinarily  the  mind  remains  clear  until  near  the  end, 
when  delirium  or  stupor  may  occur.  It  sometimes  happens  that  a  patient  who 
is  doing  very  badly,  and  has  suffered  much  from  pain,  dyspnea — due  to  disten- 
tion— and  painful  vomiting,  becomes  benumbed  as  death  approaches  and  feels 
relatively  well. 

Leucocytosis. — In  peritoneal  sepsis,  such  as  follows  rupture  of  a  gangrenous 
appendix,  no  increase  in  the  number  of  white  cells  in  the  blood  may  take  place 
throughout  the  disease.  In  ordinary  cases  of  advancing  peritonitis  a  moder- 
ate or  considerable  leucocytosis  is  the  rule.  The  differential  count  should 
always  be  made,  since  a  relative  increase  in  the  polymorpho-nuclear  forms  is 
more  significant  than  a  mere  general  increase  in  white  cells.  Thus,  while  a 
leucocyte  count  of  10,000  to  12,000  has  no  marked  weight  in  establishing  the 
diagnosis,  a  relative  increase  of  the  polymorpho-nuclear  cells  to  eighty  or  eighty- 
five  per  cent  in  such  a  count  is  strongly  suggestive  of  a  suppurative  process. 
The  value  of  the  differential  count  in  doubtful  cases  of  beginning  suppurative 
appendicitis  has,  in  my  experience,  been  considerable.  When  a  localized  peri- 
tonitis results  in  a  walled-off  abscess  the  leucocytes  may  diminish  to  normal, 
to  increase  again,  temporarily,  after  the  abscess  is  opened.  (See,  also,  Appen- 
dicitis.) 

Anorexia. — There  is  absolute  loss  of  appetite  in  cases  of  diffuse  peritonitis ; 
the  stomach  refuses  all  food.  Solids  or  fluids  swallowed  are  either  vomited  at 
once  or  after  a  longer  or  shorter  interval.     Great  thirst  is  commonly  present. 

The  Urine. — The  urine  is  diminished  in  quantity  and  high-colored.  Indi- 
can  is  often  present  in  considerable  quantity,  as  well  as  a  small  amount  of 
albumen.  When  the  peritoneal  covering  of  the  bladder  is  inflamed  there  is 
either  painful  urination  or  retention  of  urine.  If  a  considerable  exudate  com- 
presses the  bladder  there  will  be  a  frequent  desire  to  urinate. 

Pain  in  Peritonitis. — Abdominal  pain  is  one  of  the  most  constant  symp- 
toms of  all  the  forms  of  acute  peritonitis.  In  perforative  lesions — traumatic 
or  pathological — the  escape  of  putrid,  fecal,  or  purulent  material  into  the  belly 
is  followed  by  pain  of  an  intense  and  alarming  character.  The  pain  may  be 
referred  distinctly  to  the  site  of  the  perforation  at  once,  or  pain,  at  first  dif- 
fused, may,  later,  be  referred  to  some  particular  point  after  several  hours. 
Thus  a  perforated  ulcer  of  the  stomach  is  usually  accompanied  by  pain  in  the 


712  THE   PERITONEUM 

epigastrium;  ulcer  of  the  descending  portion  of  the  duodenum  by  a  pain  re- 
ferred to  a  point  to  the  right  of  the  median  line,  and  at  a  level  midway  between 
the  navel  and  the  ensiform  cartilage.  A  perforated  typhoid  ulcer  by  pain 
referred  to  the  lower  right  quadrant  of  the  belly  or  to  the  lower  half  of  the 
belly.  An  inflammation  of  the  appendix  is  accompanied  by  pain  which  may 
be  referred  to  the  right  iliac  fossa,  at  once,  or,  perhaps  more  commonly,  is  at 
first  a  general  pain  or  is  felt  around  the  umbilicus  or  in  the  epigastrium,  and 
only  after  some  hours  is  referred  to  the  appendical  region.  Peritonitis  con- 
nected with  the  uterus,  tubes,  and  ovaries  is  regularly  referred  to  the  lower 
part  of  the  belly.  If  a  single  ovary  or  tube  are  at  fault,  the  pain  will  often 
be  distinctly  unilateral.  In  peritonitis  arising  from  the  gall-bladder,  the  pain 
is  usually  referred  to  the  lower  border  of  the  ribs  at  the  edge  of  the  rectus 
muscle  on  the  right  side.  Sometimes  to  a  point  lower  down,  or  to  the  whole 
right  half  of  the  belly.  Only  rarely  is  the  pain  of  peritonitis  referred  to  the 
side  of  the  belly  opposite  to  the  lesion. 

The  location  of  the  pain  is  thus  a  useful  guide  to  the  original  lesion  in 
many  instances  during  the  earlier  hours  of  the  disease.  Later,  when  a  large 
area  is  involved,  pain  is  usually  generalized,  and  is  rarely  of  much  diagnostic 
value  as  an  indication  of  the  seat  of  the  original  focus.  There  remain  a  few 
cases,  both  of  diffuse  and  localized  peritonitis,  in  which  pain  is  not  a  striking 
symptom.  In  cases  of  peritoneal  sepsis,  without  much  inflammatory  reaction 
on  the  part  of  the  peritoneum  and  intense  septic  poisoning,  pain  is  occasionally 
slight  or  almost  absent.  The  pain  of  peritonitis  is  generally  continuous,  but  is 
rendered  worse  by  movement.  Efforts  to  move  the  bowels  by  purgatives  or 
enemata,  changing  the  position  in  bed,  the  acts  of  urinating,  vomiting,  the  hic- 
cough, all  increase  the  pain. 

Tenderness. — A  diagnostic  sign  of  much  value  is  localized  and  general 
abdominal  tenderness.  In  well-developed  cases  of  diffuse  peritonitis  this  sign 
is  so  marked  that  no  formal  examination  is  necessary  to  elicit  it.  The  patient 
protects  his  abdomen  from  movement  and  pressure  by  every  possible  means; 
even  the  weight  of  the  bedclothes  or  an  abdominal  dressing  is  complained  of, 
the  weight  of  the  hand  anywhere  on  the  abdomen  causing  increased  pain.  Under 
these  conditions  palpation  of  the  abdomen  gives  little  additional  information. 
In  the  early  stages,  before  perforation  has  occurred,  or  while  the  process  is 
still  localized,  the  signs  of  local  tenderness,  properly  elicited,  are  of  great  diag- 
nostic  aid. 

Palpation.- — Palpation  is  carried  out  in  two  ways:  The  flattened  palm  is 
placed  gently  upon  the  abdomen,  and  the  fingers  quickly  flexed  at  intervals, 
as  the  hand  slides  from  one  part  of  the  belly  to  another.  If  inflamed  perito- 
neum lies  immediately  beneath  the  hand,  the  patient  will  wince  and  complain 
of  pain.  During  this  manipulation  the  surgeon  readily  appreciates  through  his 
muscular  sense  the  comparative  degree  of  resistance  offered  to  pressure  by  the 
muscles  of  different  parts  of  the  abdominal  wall.  A  distinct  rigidity  over  one 
quadrant  of  the  belly  combined  with  localized  tenderness  is  strongly  suggestive 


PERITONITIS  713 

of  an  underlying  peritoneal  irritation.  As  a  differential  sign  between  perito- 
nitis in  its  early  stages  and  functional  disturbances  of  the  intestine  and  other 
conditions,  to  be  mentioned  later,  it  is,  I  believe,  the  most  valuable  sign  we 
know.  If  a  subcutaneous  injury  with  contusion  of  muscles  exists,  muscular 
rigidity  will  also  be  present;  such  rigidity  is  apt  to  be  confined  to  the  injured 
area.  If  such  rigidity  slowly  or  suddenly  increases  in  extent  it  is  probably 
due  to  the  spread  of  peritoneal  irritation.  In  well-developed  diffuse  peritonitis 
the  abdominal  wall  is  everywhere  rigid. 

Point  Pressure. — Another  method  of  eliciting  tenderness  is  by  what  is  com- 
monly known  as  point  pressure.  The  end  of  the  forefinger  is  used  to  depress, 
more  or  less  deeply,  different  parts  of  the  abdominal  wall.  In  this  manner  it 
is  often  possible  to  locate  quite  accurately  a  point  of  greatest  tenderness;  this 
will  often  correspond  to  the  site  of  some  particular  organ,  or  portion  of  an 
organ,  and  in  most  cases  indicates  the  origin  or  seat  of  the  peritoneal  infection. 
This  method  is  especially  valuable  when  the  lesion  is  deeply  placed,  as  in  dif- 
ferentiating between  an  affection  arising  in  the  pyloric  end  of  the  stomach 
or  duodenum  and  appendicitis ;  or  the  latter  condition  and  a  lesion  of  the  tube 
or  ovary.  The  value  of  the  sign  depends  partly  upon  the  fact  that  the  seat  of 
the  referred  pain  does  not  always  correspond  to  the  situation  of  the  lesion. 
For  example,  the  pain  of  appendicitis  is  often  referred  to  the  epigastrium 
or  umbilicus;  periovaritis,  etc.,  to  the  costal  border;  a  kidney  lesion  to  the 
course  of  the  ureter,  the  bladder,  the  testes,  even  to  the  glans  penis,  etc.  The 
sign  will  be  referred  to  under  Diseases  of  Special  Organs. 

Vomiting. — Vomiting  is  one  of  the  most  constant  symptoms  of  acute  peri- 
tonitis, both  diffuse  and  localized.  It  is  regularly  present  early  in  the  disease, 
except  under  special  conditions  to  be  mentioned  later.  Preceding  or  accom- 
panying the  abdominal  pain,  the  patient  vomits  the  contents  of  his  stomach. 
If  the  process  advances  or  becomes  diffuse  the  vomiting  is  repeated  at  fre- 
quent intervals.  The  vomited  matters  consist,  at  first,  of  the  food  previously 
swallowed,  then  of  bile-stained,  watery  fluid,  and  mucus.  The  attacks  of  vomit- 
ing are  at  first  violent  and  intensely  painful.  As  the  disease  progresses,  the 
character  of  the  vomiting  changes  to  a  sort  of  spontaneous  overflow  from  the 
stomach,  accomplished  without  apparent  muscular  effort  or  retching;  the  vom- 
ited material  suddenly  pours  out  of  the  patient's  mouth  without  warning.  In 
bad  cases  of  septic  peritonitis,  the  vomit  assumes  a  coffee-ground  character, 
and  is  of  gloomy  significance.  When  the  intestines  become  paralyzed  the  accu- 
mulation of  fermenting  material  distends  the  paralyzed  gut  and  flows  mechan- 
ically into  the  stomach ;  the  vomit  may  then  have  a  dark-brown,  green,  or  black 
color,  and  a  fecal  odor,  as  in  intestinal  obstruction.  When  coffee-ground 
vomit  occurs  after  injuries  to,  or  operations  upon,  the  stomach,  it  may  be  due 
to  bleeding  from  the  stomach  wound,  and  is  not  then  necessarilv  of  bad  sig- 
nificance. 

Absence  of  vomiting  is  noted  in  some  cases  of  gangrenous  appendicitis  with 
perforation,  and  in  other  cases  of  peritoneal  sepsis.     If  life  is  prolonged,  so  that 


714  THE  PERITONEUM 

the  peritoneum  reacts  to  the  poison  and  becomes  inflamed,  vomiting  will  then 
occur.  In  a  few  cases  of  peritonitis  following  wounds  and  perforations  of  the 
stomach  there  may  be  no  vomiting. 

Hiccough. — A  distressing  and  painful  symptom  of  acute  diffuse  peritonitis. 
Between  the  acts  of  vomiting,  reflex  spasm  of  the  diaphragm  causes,  in  many 
cases,  frequent  hiccough.  I  have  observed  it  most  often  after  wounds  and  per- 
forations of  the  stomach.     It  may  occur  in  any  case  of  extensive  peritonitis. 

Tympanites,  Meteorism — Distention  and  Paralysis  of  the  Bowel. — In  those 
speedily  fatal  cases  of  peritoneal  sepsis  followed  by  death  in  a  few  hours  with 
but  little  true  peritonitis,  the  belly  is  often  flat  or  retracted;  if  the  patient  sur- 
vives a  day,  the  belly  will  become  distended.  In  localized  peritonitis — resulting 
in  a  walled-off  abscess — distention  may  be  slight.  In  all  cases  of  progressive 
and  diffuse  purulent  peritonitis  distention  of  the  bowels  with  gas,  and  marked 
enlargement  of  the  abdomen,  is  regularly  present,  giving  a  tympanitic  note  on 
percussion.  Upward  pressure  upon  the  liver  and  diaphragm  causes  diminu- 
tion or  loss  of  liver  dullness  and  dyspnea.  In  bad  cases  the  distended  bowel  is 
paralyzed,  its  contents  undergo  putrefactive  changes  with  the  production  of 
much  gas.  At  the  beginning  of  the  attack  there  may  be  one  or  more  diarrheal 
movements.  As  the  inflammation  becomes  diffuse,  and  the  wall  of  the  gut  infil- 
trated and  inflamed,  constipation  becomes  absolute.  During  the  earlier  stages 
ineffective  painful  peristaltic  movements  occur,  which  may  sometimes  be  heard 
as  gurgling  sounds  through  a  stethoscope  placed  on  the  abdominal  wall ;  later, 
they  are  abolished.  Thorough  paralysis  of  the  gut  is  not  recovered  from.  A 
free  movement  from  the  bowels  after  an  operation  for  peritonitis  is  a  cheering 
event  to  both  surgeon  and  patient.  Septic  peritonitis  following  abdominal 
operations  of  all  kinds  is  occasionally  attended  by  diarrhea  of  a  septic  char- 
acter. Some  cases  of  puerperal  septicemia  complicated  by  peritonitis  are  accom- 
panied by  diarrhea  during  the  time  when  the  peritoneum  is  not  extensively 
inflamed. 

Physical  Signs  of  a  Peritoneal  Exudate. — Determination  of  the  pres- 
ence of  an  exudate  in  the  abdomen  by  palpation  and  percussion  is  possible  in 
some  cases  of  peritonitis,  not  in  others.  As  stated,  in  peritoneal  sepsis,  the 
amount  of  exudate  is  often  small  and  gives  no  physical  signs  of  its  presence. 
In  cases  of  purulent  peritonitis  of  a  rapidly  progressive  character  without 
the  formation  of  distinct  loculi  of  pus  walled  off  by  fibrin,  it  is  rarely  possible 
to  find  flatness  on  percussion  in  the  flanks,  indicating  the  presence  of  free 
fluid.  Flatness  here  may  be  found,  due  to  coils  of  gut  distended  by  fluid. 
Pocking  motions  may  give  rise  to  splashing  sounds,  indicating  a  mixture  of 
gas  and  liquid  in  the  gut.  These  signs  are  of  but  slight  value  in  diagnosis. 
Pathological  and  traumatic  perforations  of  the  stomach  and  intestine  are  some- 
times followed  by  the  escape  of  gas  into  the  peritoneum.  The  gas  tends  to 
accumulate  in  the  upper  part  of  the  belly.  Absence  of  liver  dullness  may  thus 
be   caused. 

In   cases  of   progressive   fibrino-punilent  peritonitis   with   walled-off  loculi 


PERITONITIS  715 

of  pus,  and  in  cases  of  localized  peritonitis  with  the  formation  of  a  single 
large  abscess,  or  a  massive  fibrinous  exudate,  a  distinct  sense  of  resistance, 
and,  in  some  cases,  a  sense  of  elastic  fluctuation  with  dullness  or  flatness  on  light 
percussion,  may  be  present.  The  rigidity  of  the  abdominal  muscles,  and  the 
pain  caused  by  the  manipulation,  often  render  the  examination  unsatisfactory. 
Under  a  general  anesthetic  the  tense  muscles  are  relaxed,  and  it  is  often  easy 
to  map  out  a  definite  mass  of  variable  size  through  the  abdominal  wall.  Such 
a  mass  may  be  agglutinated  and  infiltrated  coils  of  gut  covering  or  inclosing 
an  abscess  cavity ;  tympanitic  resonance  will  then  be  present  over  the  tumor. 
It  may  be  an  inflamed  mass  of  omentum  alone,  or  inclosing  an  inflamed  appen- 
dix and  an  abscess,  or  the  appendix  itself,  or  some  other  organ,  or  a  strangulated 
coil  of  gut,  or  a  distended  gall-bladder,  or  actually  an  abscess,  a  portion  of 
whose  boundary  is  formed  by  the  abdominal  wall,  or  a  broken-down  new  growth, 
etc.  In  some  cases  the  surgeon  may,  from  concomitant  signs  and  symptoms, 
conclude  correctly  as  to  the  exact  nature  of  the  tumor ;  in  others  he  cannot. 
(See  Diseases  of  the  Individual  Viscera.) 

Examination  Per  Rectum  or  Per  Vaginam. — Examination  per  rectum 
or  per  vaginam — one  or  two  fingers  being  introduced  for  the  purpose,  the  other 
hand  being  used  to  palpate  the  abdominal  wall — should  never  be  omitted  in 
peritonitis  the  origin  of  which  is  doubtful.  Much  valuable  information  may 
thus  be  obtained,  and  errors  avoided.  A  boggy  or  fluctuating  tumor  in  Doug- 
las's cul-de-sac ;  lesions  of  the  uterus,  tubes,  and  ovaries ;  of  the  bladder,  prostate, 
or  seminal  vesicles ;  and  many  other  conditions  may  be  found  or  eliminated. 

The  Aspirating  Needle  and  Trocar. — In  only  a  few  conditions  is  the 
surgeon  justified  in  introducing  a  needle  or  trocar  through  the  abdominal  wall 
for  the  purpose  of  detecting  the  presence  or  character  of  an  acute  inflammatory 
exudate  supposed  to  lie  within  the  cavity  of  the  peritoneum.  No  information 
is  thus  obtainable  which  cannot  be  obtained  more  certainly  and  with  far  less 
danger  through  a  small  incision.  Certain  intra-abdominal  organs  and  lesions 
may  be  explored  with  a  needle  with  safety  under  certain  conditions  to  be 
described,  notably  in  abscess  of  the  liver  and  subphrenic  abscess.  The  explor- 
ing needle  and  aspirating  syringe  are  very  rarely  used  by  experienced  surgeons 
to  explore  either  acute  or  chronic  intraperitoneal  lesions.  The  danger  of  leak- 
age of  septic  or  irritating  fluids  into  free  peritoneum  after  the  needle  is  with- 
drawn is  great ;  and  such  leakage  is  often  followed  by  fatal  sepsis  or  peri- 
tonitis. 

Danger  of  Delay  in  Operating  in  Cases  of  Localized  Peritonitis. — 
The  diagnosis  of  a  beginning  acute  peritonitis  having  been  made,  it  is  impor- 
tant to  remember  that  we  cannot  tell  whether  the  process  will  remain  localized 
or  become  diffuse.  Postponement  of  operation  in  these  cases  thus  involves  very 
grave  risks. 

Differential  Diagnosis. — A  number  of  pathological  conditions  may  simu- 
late beginning  peritonitis.  When  diffuse  peritonitis  is  well  developed  it  is 
not  likely  to  lie  confounded  with  any  other  disease  except  acute  intestinal  obstruc- 


716  THE   PERITONEUM 

tion,  since  the  former  may  follow  the  latter ;  and  peritonitis  is,  as  stated,  when 
diffuse,  commonly  associated  with  intestinal  paralysis  and  total  inability  to 
evacuate  the  bowels. 

Intestinal  Colic. — The  pain  is  intermittent,  or  varies  from  moment  to 
moment  in  intensity.  Abdominal  tenderness  is  absent ;  firm  pressure  on  the 
abdomen  often  relieves  the  pain;  there  is  no  rigidity  of  the  abdominal  wall. 
The  pulse  and  temperature  are  not  affected ;  there  is  no  vomiting. 

Acute  G 'astro-enteritis. — There  is  diarrhea  as  well  as  vomiting.  The  abdom- 
inal pain  and  tenderness  are  general.  There  is  no  localized  muscular  rigidity. 
There  may,  however,  be  fever  and  a  rapid  pulse.  Occasionally  the  leucocyte 
count  may  be  high,  the  differential  count  will  fail  to  show  a  marked  relative 
increase  in  the  polymorpho-nuclear  leucocytes.  I  have  found  the  following 
precaution  a  wise  one.  ^Yhen  called  to  see  a  patient  who  has  an  attack  of 
abdominal  pain  and  vomiting,  the  physical  examination  being  negative,  see  and 
examine  that  patient  again  in  six  hours,  and  visit  him,  at  suitable  intervals, 
at  least  twice  during  the  following  day.  Give  no  morphin  until  sure  he  has 
or  has  not  beginning  peritonitis.  A  diagnosis  of  beginning  peritonitis  having 
been  made,  and  operation  decided  upon,  a  small  dose  of  morphin  may  be  given 
if  pain  is  excessive,  and  the  operation  is,  of  necessity,  delayed  some  hours. 

Isephritic  Colic. — The  pain  of  nephritic  colic  may  be  referred  to  the  abdo- 
men in  such  a  way  as  to  suggest  peritonitis.  There  is  often  vomiting.  As 
pointed  out  under  the  diagnosis  of  Renal  Calculus,  pain  radiating  into  the 
groin,  testis,  etc.,  is,  while  characteristic,  by  no  means  always  present  in  cases 
of  renal  calculus.  There  will  usually  be  tenderness  on  deep  sudden  pressure, 
or  from  a  light,  quick  blow  over  the  last  rib,  when  a  stone  lies  in  the  pelvis 
of  the  kidney.  Urinary  signs  and  symptoms  should  be  sought  for — anuria, 
oliguria,  and  abnormal  ingredients,  especially  red  blood  cells  in  the  urine. 
Abdominal  distention  does  not  develop.  The  tenderness  and  rigidity  of  the 
abdominal  wall  are,  if  present,  confined  to  the  region  of  the  kidney,  or  are 
felt  along  the  course  of  the  ureter.  General  abdominal  tenderness  and  rigidity 
are  not  present.  Careful  observation  of  the  case  for  several  hours  usually 
enables  us  to  exclude  peritonitis  without  difficulty. 

Uremia. — Uremia  is  sometimes  associated  with  severe  abdominal  pain.  The 
local  signs  of  peritonitis  are  absent.  There  may  be  coma  or  convulsions  and 
suppression  of  urine.  Urine  passed,  or  withdrawn  through  a  catheter,  will 
show  the  evidences  of  nephritis — albumen,  casts,  a  low  specific  gravity,  and 
small  content  of  urea. 

Intestinal  Obstruction. — Both  intestinal  obstruction  and  diffuse  peritonitis 
are  accompanied  by  frequent  vomiting.  In  the  former  the  vomited  matter 
regularly  acquires  a  fecal  character  after  the  obstruction  has  existed  for  a  cer- 
tain time,  and  is  absolute.  In  the  latter,  fecal  vomiting  is  common  after  the 
gut  is  paralyzed.  Both  are  accompanied  by  distention  of  the  abdomen.  In 
many  cases  of  intestinal  obstruction  peritonitis  finally  develops  as  the  result 
of  gangrene  or  perforation  of  the  gut     The  bacteria  are  not  confined  by  the 


LOCALIZED   PEEITONITIS  717 

intestinal  wall  when  deprived  of  its  vitality,  and  thus  infect  the  peritoneum. 
In  advanced  cases  of  both  conditions  it  may  be  impossible  to  say  from  the 
clinical  symptoms  which  of  the  two  was  originally  present.  During  the  earlier 
stages  of  intestinal  obstruction,  before  peritonitis  has  occurred,  a  differential 
diagnosis  is  usually  not  difficult. 

The  abdominal  distention  in  acute  obstruction  is  often  localized  in  some 
particular  part  of  the  belly.  Abdominal  tenderness  is  confined  to  the  seat  of 
the  obstruction,  or  if  this  be  deeply  placed  in  the  belly,  marked  tenderness  may 
be  absent  except  on  deep  pressure.  Rigidity  of  the  belly  wall  is  absent  or  less 
marked  than  in  peritonitis.  The  distended  coils  of  gut  in  obstruction  can  often 
be  seen  and  felt  if  the  belly  wall  is  moderately  thin.  Peristaltic  movements 
are  often  visible  and  palpable  in  the  distended  coils,  and  gurgling  sounds  are 
apt  to  be  much  more  marked  and  distinct  on  auscultation  than  is  the  case  in 
peritonitis,  even  in  its  early  stage.  In  obstruction  neither  feces  nor  gas  are 
expelled  per  rectum.  In  peritonitis  an  enema  often  brings  away  some  small 
amount  of  feces  and  gas,  unless  the  paralysis  of  the  gut  is  absolute. 

Fever  is  not  present  in  obstruction  unless  the  peritoneum  is  inflamed ;  it  is 
often  present  in  peritonitis.  The  pain  of  peritonitis  is  continuous.  In  the  early 
stages  of  obstruction  the  pain  is  apt  to  occur  in  sudden  severe  attacks  corre- 
sponding to  peristaltic  waves,  and  may  even  be  intermittent.  Leucocytosis  is, 
with  the  exceptions  noted,  regularly  present  in  peritonitis,  absent  in  obstruc- 
tion. The  general  condition  of  patients  suffering  from  obstruction  is  at  first 
good ;  symptoms  of  progressive  prostration  increase  from  hour  to  hour  until 
death,  unless  the  obstruction  be  relieved.  Cases  of  peritoneal  sepsis,  and,  in 
general,  all  cases  of  peritonitis  due  to  perforation  of  the  intestinal  tract,  are 
suddenly  and  violently  ill  from  the  start.  In  the  cases  of  gradually  spreading 
fibrino-purulent  peritonitis  and  localized  peritonitis  this  sharp  distinction  does 
not  obtain. 

Localized  Peritonitis. — From  the  foregoing  description  it  may  be  gathered 
that  the  diagnosis  of  advanced  diffuse  purulent  peritonitis  offers  no  difficulties. 
Unfortunately,  in  its  later  stages,  the  condition  is  a  desperate  one,  only  rarely 
to  be  relieved  by  surgical  means.  In  order  to  be  efficient,  treatment  must  be 
applied  while  the  disease  is  still  localized,  or  before  the  process — if  no  limit- 
ing adhesions  are  formed — has  produced  fatal  sepsis  or  permanent  paralysis 
of  the  gut.  A  large  proportion  of  cases  of  suppurative  and  perforative  lesions 
of  the  abdominal  viscera  are  accompanied  by  peritonitis,  at  first  distinctly 
localized.  In  some  instances  the  process  remains  shut  off  by  adhesions  from 
the  general  cavity  of  the  belly ;  in  others,  sooner  or  later,  becomes  generalized ; 
and,  in  still  others,  complications  of  a  dangerous  or  fatal  character  occur,  due 
to  septic  thrombosis  of  veins  or  to  lymphatic  absorption.  It  is,  therefore,  impor- 
tant that  localized  foci  of  suppuration  in  the  cavity  of  the  abdomen  should  be 
recognized  very  early  in  order  that  appropriate  surgical  treatment  may  be 
applied. 

The  character  of  the  exudate  in  localized  peritonitis  may  be  serous,  fibrinous, 


718  THE   PERITONEUM 

purulent,  or  putrid,  or  a  combination  of  these  ingredients.  In  a  good  many 
cases  a  purulent  exudate  walled  off  by  fibrin  may  be  accompanied  by  a  consid- 
erable effusion  of  serum,  free  in  the  peritoneum,  as  the  result  of  peritoneal 
irritation.     Such  serum  is  often  found  to  be  sterile. 

The  symptoms  of  localized  peritonitis  resemble  at  the  outset  the  symp- 
toms of  beginning  diffuse  peritonitis,  as  already  described.  The  patient  is 
seized  with  severe  abdominal  pain  and  vomiting.  The  pain,  as  stated,  may  at 
first  be  general,  and  is  subsequently  localized  near  the  seat  of  the  lesion. 
There  is  localized  tenderness  and  rigidity  of  the  abdominal  wall;  the  remainder 
of  the  abdomen  remains  soft  and  not  tender.  There  may  be  fever,  moderate 
or  high,  or  a  normal  temperature  may  be  present.  The  pulse  is  usually  in- 
creased in  frequency,  90  to  100  to  120  beats  per  minute,  but  remains  of  good 
quality.  Abdominal  distention  may  be  absent  or  moderate.  The  general  con- 
dition of  the  patient  remains  good.  The  vomiting  may  be  repeated  once  or 
twice,  but  is  not  continuous.  The  inflamed  portions  of  intestine  are  more  or 
less  distended  and  temporarily  paralyzed,  but  the  bowels  can  usually  be  moved 
more  or  less  thoroughly  by  means  of  an  enema.  The  patient  does  not  look 
seriously  ill.  The  expression  of  the  face  is  not  drawn,  pinched,  and  anxious, 
but  calm,  even  cheerful.  An  increased  leucocyte  count  with  relative  increase 
of  the  polymorpho-nuclear  cells  is  quite  regularly  present.  If  the  exudate  be 
fibrino-purulent  and  completely  walled  off  the  leucocyte  count  may  fall  nearly 
to  normal,  to  rise  again  temporarily  after  operation.  Locally,  after  the  process 
has  existed  for  a  day  or  two,  it  is  usually  possible  to  discover  by  palpation 
a  definite  intra-abdominal  mass,  composed  of  inflammatory  exudate  and  of 
inflamed  and  infiltrated  tissues  and  organs,  as  already  noted  under  progressive 
peritonitis. 

The  subsequent  course  of  localized  peritonitis  is  very  varied.  If  the  exu- 
date is  serous  and  fibrinous  merely,  the  result  of  mechanical  or  chemical  irri- 
tation, or  of  a  septic  process  in  the  gut,  the  appendix,  the  gall-bladder,  the ' 
tubes,  or  other  structure,  which  does  not  actually  infect  the  peritoneum,  the 
exudate  may  gradually  be  absorbed,  with  subsidence  of  all  the  symptoms.  Or- 
ganized adhesions  are  usually  formed,  more  or  less  extensively,  between  the 
inflamed  peritoneal  surfaces.  These  may  remain  for  some  weeks  or  months, 
and  finally  disappear;  or  in  other  cases  remain  as  permanent  bands  or  thick- 
enings of  fibrous  tissue,  at  times  thin  and  fragile,  at  times  dense  and  firm, 
according  to  the  intensity  of  the  antecedent  inflammation.  A  thoroughly  walled- 
off  purulent  exudate,  if  of  small  size,  may  remain  innocuous,  and  finally  become 
sterile.  This  seems  to  be  especially  true  of  localized  purulent  exudates  originat- 
ing in  the  tubes  and  ovaries  the  result  of  gonorrheal  infection.  It  is  rare  that 
purulent  foci  bearing  the  ordinary  pus-producing  organisms  behave  in  this 
manner;  the  outcome  of  these  is  various. 

The  abscess  may  increase  in  size,  and  slowly  or  suddenly  invade  the  gen- 
eral cavity  of  the  belly.  It  may,  finally,  rupture  into  the  intestine,  the  blad- 
der, the  vagina,  the  rectum  occasionally,  with  eventual  cure.     The  abdominal 


LOCALIZED   PERITONITIS  719 

wall  may  be  invaded  with  the  production  of  a  localized  abscess  or  ;i  spreading 
septic  phlegmonous  inflammation.  Infection  of  the  abdominal  lymphatics  may 
occur  with  the  production  of  abscesses  originating  in  the  mesenteric  or  retro- 
peritoneal lymph  nodes.  Lymphatic  infection  of  the  pleura  and  pericardium 
is  not  uncommon.  Infection  of  the  mesenteric  veins  usually  eventuates  in  a 
spreading  septic  thrombophlebitis,  finally  involving  the  portal  vein  and  its 
distribution  in  the  liver,  ending  in  death  with  pyemic  symptoms.  Localized 
peritonitis  involving  the  major  part  of  the  coils  of  small  intestine,  although 
the  process  may  be  limited  above  by  the  omentum  and  transverse  colon,  usually 
gives  the  signs  and  symptoms  of  generalized  peritonitis.  One  of  the  most 
serious  forms  of  localized  peritonitis  is  subdiaphragmatic  abscess.  (See  section 
on  this  topic.) 

Uterine  Sepsis. — Septic  infections  of  the  interior  of  the  uterus — whether 
occurring  after  labor,  or  as  the  result  of  operations  upon  the  interior  of  the 
uterus  (whether  pregnant  or  not) — may  result  in  septicemia  through  lym- 
phatic absorption.  Peritoneal  irritation  or  inflammation,  when  present,  exists 
merely  as  a  part  of  the  general  infection.  The  condition  is  rarely  amenable  to 
operative  treatment.  Less  intense  infections  of  the  endometrium,  whether  due 
to  puerperal  infection,  to  operative  measures  on  the  interior  of  the  uterus  (curet- 
tage, cauterizations,  irrigations),  frequently  result  in  peritoneal  irritation  or 
inflammation.  The  infectious  material  reaches  the  peritoneum  through  the 
orifices  of  the  Fallopian  tubes.  The  exudate  may  be  serous,  fibrinous,  or  puru- 
lent, and  may  result  merely  in  more  or  less  extensive  adhesions,  or  in  the 
formation  of  a  pelvic  abscess.  Owing  to  the  proximity  of  the  rectum,  these 
abscesses  are  frequently  infected  with  the  bacillus  coli.  The  pus  has  then 
a  fetid  odor ;  there  may  be  the  formation  of  gas.  Such  an  abscess  commonly 
forms  behind  the  uterus  in  Douglas's  pouch;  less  often  in  front  of  the 
broad  ligament.  Rupture  of  such  abscesses  into  the  gut  or  into  the  vagina  is 
not  uncommon.  The  abscess  may  attain  a  very  large  size,  fill  the  pelvis,  and 
present  above  the  pelvic  brim  as  a  tender,  fluctuating  abdominal  tumor. 

The  type  of  the  disease  is  rather  subacute  or  chronic,  a  generalized  peri- 
tonitis very  rarely  follows.  The  constitutional  infection  is  seldom  marked. 
These  patients  are  often  up  and  about  with  a  large  pelvic  abscess.  They  suffer 
from  pain  in  the  sacral  region,  sometimes  from  pressure  symptoms  upon  the 
bladder  and  rectum.  Elevation  of  temperature  and  an  increased  pulse  rate 
may  or  not  be  present.  Leucocytosis  will  be  present  or  absent,  according  as  the 
process  is  more  acute  or  chronic,  and  more  or  less  completely  shut  off  by  adhe- 
sions. Menstrual  disturbances  are  usually  present — pain,  menorrhagia,  metror- 
rhagia. Usually,  also,  endometritis  and  a  more  or  less  profuse  muco-purulent 
discharge  from  the  uterus.  I  recently  operated  on  a  case  in  which  a  small 
pelvic  abscess  connected  with  the  ovary  was  ruptured  by  external  violence,  an 
extensive  purulent  peritonitis  followed  at  once,  giving  very  severe  symptoms. 

Gonorrheal  Peritonitis. — Gonorrheal  infection  of  the  pelvic  peritoneum 
is  exceedingly  frequent  in  females.     Such  an  infection  may  occur  in  an  acute 


720  THE   PERITONEUM 

form  in  a  woman  previously  healthy  during  an  acute  attack  of  gonorrheal  in- 
flammation of  the  endometrium.  Intra-uterine  medication  or  operation  is  a 
not  infrequent  cause  of  the  extension  of  the  process.  In  the  presence  of  an 
acute  gonorrhea  the  patient  is  seized  with  violent  pain  in  the  lower  part  of 
the  abdomen,  vomiting,  prostration,  a  rise  of  temperature,  an  accelerated 
pulse,  together  with  abdominal  rigidity  and  tenderness  which  may  be  on  one 
or  both  sides  of  the  median  line.  If  the  peritonitis  proceeds  from  leakage  of 
gonorrheal  pus  from  the  right  tube,  if  the  patient  is  young  and,  presumably, 
a  virgin,  in  the  entire  absence  of  chronic  inflammatory  thickening  in  the  tubes, 
ovaries,  and  broad  ligaments,  as  determined  by  bimanual  examination,  a  diag- 
nosis of  acute  appendicitis  will  probably  be  made.  I  have  seen  two  such  cases 
within  the  past  year.  The  patients  were  aged  fourteen  and  sixteen  years 
respectively. 

A  differential  diagnosis  is  very  desirable,  since  in  acute  gonorrheal  peri- 
tonitis operation  may  sometimes  be  postponed  with  advantage.  It  is  therefore 
very  desirable  to  seek  for  the  presence  of  gonococci  in  the  discharge  from 
Bartholin's  glands,  the  urethra,  and  the  cervix  when  any  doubt  at  all  exists 
as  to  the  diagnosis.  These  patients  are  generally  quite  ill;  there  is  no  mass 
to  be  felt  in  the  region  of  the  appendix.  They  are  not  as  ill  as  those  who 
have  a  diffuse  or  spreading  peritonitis  from  the  ordinary  streptococcus  and 
saprophytic  infection  following  perforative  lesions  of  the  intestine.  Under 
suitable  conservative  treatment  they  quite  often  improve  after  some  days.  A 
certain  number  of  cases  do  run  a  violent  and  sometimes  fatal  course,  probably 
as  the  result  of  mixed  infection.  They  require  immediate  operation.  In  the 
subacute  and  chronic  forms,  gonorrheal  pelvic  peritonitis  existing,  as  it  does, 
in  combination  with  endometritis,  salpingitis  (pus-tubes),  and  ovarian  abscess, 
is  a  condition  so  frequent  that  in  any  active  service  in  a  general  hospital  in 
the  city  of  New  York  one  or  more  of  these  cases  forms  almost  a  daily  part 
of  the  surgeon's  work. 

Diagnosis  of  Pelvic  Peritonitis. — Without  going  particularly  into  the 
pathology  and  symptoms  of  these  cases,  it  may  be  said  that  the  diagnosis  of 
pelvic  peritonitis  depends  partly  upon  a  history  of  infection  following  labor — 
natural  or  induced — an  antecedent  intra-uterine  operation  or  instrumentation, 
a  history  of  gonorrheal  infection,  or  of  pelvic  pain,  menstrual  disorders — irregu- 
lar, profuse,  and  usually  painful  menstruation — endometritis,  pressure  symp- 
toms upon  the  bladder  and  rectum,  partly  upon  the  presence  of  constitutional 
symptoms  of  pyogenic  infection  in  acute  cases,  partly  upon  the  results  of 
physical  examination. 

Bimanual  Palpation. — The  most  useful  method  of  examining  the  pelvic 
viscera  of  the  female  for  the  detection  of  inflammatory  exudates  and  other 
lesions  is  bimanual  palpation,  one  examining  hand  being  placed  on  the  surface 
of  the  abdomen,  one  or  two  fingers  of  the  other  hand  being  introduced  into 
the  vagina  if  the  patient  is  an  adult  woman,  or  into  the  rectum  if  she  be  a 
child  or  young  virgin.     Nervous  patients,  virgins,  those  who  have  some  acute 


LOCALIZED   PERITONITIS  721 

inflammatory  process  in  the  pelvis,  stont  women  with  thick  abdominal  Avails, 
and  in  all  cases  where  the  patient  is  unable  or  unwilling  to  relax  the  abdom- 
inal muscles  completely  during  the  examination,  can  only  be  examined  in  a 
satisfactory  manner  under  a  general  anesthetic.  I  am  in  the  habit,  in  hospital 
work  among  such  cases,  of  deferring  a  thorough  bimanual  examination  until 
the  patient  is  anesthetized  and  prepared  for  any  operation  which  may  be 
found  necessary. 

In  conducting  the  examination  without  an  anesthetic  the  patient  should  be 
prepared  by  a  previous  purgative  and  enema  to  insure  an  empty  rectum ;  the 
bladder  should  be  emptied  just  before  the  examination;  all  tight  clothing — 
stays  and  waist  bands — should  be  removed.  The  patient  should  be  placed  in 
the  lithotomy  position  upon  a  table  the  height  of  which  is  such  that,  as  the 
surgeon  stands  in  front  of  his  patient,  her  symphysis  pubis  should  be  on  a  level 
a  little  lower  than  his  elbow.  The  patient's  head  and  shoulders  should  be 
supported  by  pillows,  since  by  having  the  upper  part  of  the  body  a  little  raised 
the  abdominal  muscles  are  more  readily  and  completely  relaxed.  The  knees 
and  thighs  should  be  strongly  flexed  and  the  feet  comfortably  supported.  The 
feet  should  be  near  together  rather  than  far  apart,  the  knees  well  separated. 
Due  care  should  be  exercised  not  to  offend  the  patient's  sense  of  modesty.  The 
examination  should  be  conducted,  whenever  practicable,  in  the  presence  of  a 
nurse. 

Preceding  the  bimanual  examination  the  surgeon  puts  on  sterile  rubber 
gloves,  or,  if  these  are  not  obtainable,  he  washes  and  disinfects  his  hands  by 
one  of  the  several  known  methods.  The  external  genitals  are  inspected.  The 
existence  of  a  purulent  discharge  from  Bartholin's  glands  and  from  the  urethra 
is  strongly  suggestive  of  gonorrhea.  Each  gland  is  gently  pinched  between 
the  finger  and  thumb,  and  the  urethra  milked  by  a  forefinger  introduced  into 
the  vagina  and  pressed  upward  against  the  pubes.  If  a  drop  of  pus  appears 
in  either  case,  microscopic  examination  will  usually  show  the  presence  of  the 
gonococcus ;  a  purulent  discharge  from  the  cervix  may  be  due  to  a  similar 
cause.  A  bloody,  brown,  and  foul-smelling  discharge  is  strongly  suggestive 
of  cancer.  A  scanty,  bloody  discharge,  with  a  cadaveric  odor,  with  a  history 
of  a  recent  labor  or  abortion,  indicates  sapremia  from  retained  placenta  or 
blood  clot. 

The  index  and  middle  finger  of  one  hand  (or  the  index  alone),  being  lubri- 
cated, are  introduced  into  the  vagina.  The  palpation  of  the  pelvic  organs  by 
the  vaginal  fingers  is  made  with  the  palmar  surface  of  the  tips  of  the  fingers ; 
in  order  to  reach  deeply  into  the  pelvis,  a  good  deal  of  pressure  must  some- 
times be  exerted.  The  perineum  and  floor  of  the  pelvis  must  be  invaginated 
to  some  extent.  In  order  to  accomplish  this  properly,  and  at  the  same  time 
preserve  the  mobility  of  the  examining  fingers,  the  surgeon  rests  his  elbow 
against  his  own  pelvis  and  pushes  forward  his  forearm  and  hand  by  the  weight 
of  his  body.      The  thumb  of  the  vaginal  hand  rests   against  the  pubes ;   the 

fourth  and  fifth  fingers  may  be  strongly  flexed  or  widely  abducted,  and  held 

47 


722  THE  PERITONEUM 

against  the  perineum.  The  palmar  surface  of  his  other  hand  is  used  to  de- 
press the  abdominal  wall  just  above  the  pubes  so  that  the  pelvic  organs  can  be 
brought  successively  between  the  two  hands,  and  their  form,  position,  size, 
consistence,  mobility,  sensibility  noted.  The  outside  hand  is  used  rather  as 
a  point  of  support  against  which  the  vaginal  fingers  pass  the  pelvic  viscera 
in  review. 

A  moderate  amount  of  practice  only  is  necessary  to  enable  one  to  map  out 
clearly  the  normal  pelvic  viscera,  provided  the  manipulations  are  conducted 
in  the  right  way.  The  alterations  produced  by  disease  are  some  of  them  easy, 
some  of  them  difficult  to  recognize  without  a  good  deal  of  experience.  The 
reader  is  referred  to  works  on  gynecology  for  the  details  of  diagnosis  in  uterine 
displacements,  etc.  If  the  patient  holds  the  abdominal  muscles  rigid,  she  may 
be  told  to  breathe  through  the  mouth.  In  the  case  of  young  virgins  and 
children,  a  very  satisfactory  examination  may  be  made  through  the  rectum. 
For  a  thorough  examination  a  general  anesthetic  is  most  desirable  in  many 
cases.  In  normal  and  not  neurotic  or  hysterical  women,  a  complete  pelvic 
examination  may  be  made  without  causing  pain  unless  the  ovary  be  rather 
severely  pinched.     In  all  inflammatory  conditions  this  will  not  be  the  case. 

Fixation  of  Pelvic  Structures. — A  common  character  of  all  cases  of  acute 
or  chronic  pelvic  peritonitis  is  loss  of  or  diminished  mobility  of  the  pelvic 
organs.  This  may  be  slight  and  confined  to  one  tube  or  ovary,  or,  in  old  and 
extensive  cases  of  gonorrheal  peritonitis,  when  frequently  repeated  outpourings 
of  infectious  pus  have  occurred  from  the  mouths  of  the  Fallopian  tubes,  the 
entire  contents  of  the  pelvis  may  be  cemented  together  into  a  firm,  hard  mass 
in  which  the  separate  viscera  can  in  no  wise  be  differentiated  except  by  a 
careful  intra-abdominal  dissection.  In  the  history  of  these  cases  the  patients 
will  complain  of  severe  attacks  of  abdominal  pain,  recurring  at  intervals  during 
a  period  of  years,  sometimes  accompanied  by  vomiting,  and  usually  referred 
to  indiscretions  in  diet,  to  taking  cold,  overfatigue,  and  the  like.  The  condi- 
tion long  ago  received  a  special  name — "  Colica  scortorum  "  (harlot's  colic). 
The  surgeon  will  do  well  to  remember  that  such  attacks  are  by  no  means  con- 
fined to  this  class. 

Upon  examining  such  a  case  the  uterus  will  be  found  immovable,  the  pelvic 
floor  everywhere  hard  and  boardlike ;  the  abdominal  hand  will  meet  a  diffuse 
sense  of  resistance  extending  across  the  brim  of  the  pelvis.  In  many  of  these 
cases  abscess  will  be  present.  The  most  common  location  for  the  accumulation 
of  pus  is  the  Douglas  pouch ;  in  such  cases  a  boggy  or  fluctuating  area  may  be 
felt  behind  the  cervix,  or  a  distinct  bulging  in  this  region  may  be  felt,  and 
even  seen,  by  placing  the  patient  in  the  genu-pectoral  position  and  introducing 
a  speculum  into  the  vagina.  The  viscera  tend  to  fall  toward  the  diaphragm, 
air  enters  the  vagina,  and  distinct  bulging  in  the  posterior  fornix  may  be 
visible.  The  diagnosis  may  be  confirmed  by  the  introduction  of  an  aspirating 
needle,  if  desired.  In  other  cases  the  abscess  will  be  wholly  or  partly  included 
in  the  ovary,  or  its  walls  may  be  formed  by  the  ovary,  tube,  and  broad  ligament, 


LOCALIZED   PERITONITIS  723 

or  the  posterior  surface  of  the  nterijs;  rarely  by  the  anterior  surface  of  the 
uterus,  broad  ligament,  and  bladder.  Under  anesthesia  these  various  condi- 
tions may  be  mapped  out  more  or  less  clearly  by  vaginal  or  rectal  touch,  com- 
bined with  abdominal  palpation.  Pain,  tenderness,  and  abdominal  rigidity 
make  a  thorough  examination  rather  difficult  when  the  patient  is  conscious. 

In  some  cases,  not  so  far  advanced,  the  surgeon's  fingers  will  pass  from 
the  fundus  of  the  more  or  less  movable  uterus  outward,  and  feel  on  one  or 
both  sides  the  enlarged  and  thickened  tube.  Such  a  tube  may  feel  like  a  hard, 
firm,  cylindrical  cord,  of  variable  size  and  length,  or  as  a  large  sausage-shaped 
tumor,  thicker  than  a  man's  thumb.  Such  a  tube  may  be  adherent  or  free, 
and  can  usually  be  traced  outward  or  backward  into  an  enlarged  and  fixed 
ovary.  Gravity  frequently  causes  the  inflamed  tube  and  ovary  to  fall  down- 
ward and  backward  in  Douglas's  pouch,  there  to  become  adherent.  Consider- 
able backward  rotation  of  the  tube  and  ovary  commonly  occurs,  so  that  in 
many  cases  the  tube  and  ovary  come  to  be  wrapped  up  in  the  broad  ligament, 
and  to  lie  as  a  conglomerate  mass  buried  in  adhesions  behind  the  uterus  at 
the  bottom  of  the  pelvis.  A  knowledge  of  this  rotation  enables  the  surgeon 
to  untwist  an  apparently  hopeless  tangle  with  comparative  ease  when  removing 
the  diseased  structures.  In  all  these  cases  the  rectum,  the  sigmoid  flexure  of 
the  colon,  and  coils  of  small  intestine  are  all  likely  to  become  adherent  to  the 
inflamed  uterine  appendages,  and  the  walls  of  abscess  cavities  are  not  infre- 
quently formed  in  part  by  coils  of  intestine. 

The  right  tube  and  ovary  when  inflamed  often  become  adherent  to  the 
vermiform  appendix  and  drag  this  structure  down  into  the  pelvis.  The 
appendix  may  thus  become  involved  in  the  inflammatory  process,  and  be 
found  at  the  operation  incorporated  in  an  inflammatory  mass  consisting  of 
tube,  ovary,  and  appendix.  In  these  cases  the  diagnosis  of  the  true  state 
of  affairs  may  be  puzzling  before  opening  the  abdomen.  Symptoms  and  signs 
of  chronic  appendicitis  and  of  disturbances  of  the  sexual  organs,  together  with 
attacks  of  pelvic  peritonitis,  may  all  be  present.  Fortunately  the  right  tube  and 
ovary,  together  with  the  appendix,  can  all  be  removed  through  an  intermus- 
cular incision  in  the  right  lower  quadrant  of  the  belly  unless  the  abdominal 
wall  be  very  thick.     In  such  cases  a  median  cut  may  be  necessary. 

Localized  Peritonitis  Secondary  to  Inflammations  of  the  Gall- 
bladder.— Localized  peritonitis  is  often  secondary  to  inflammations  of  the 
gall-bladder,  caused  usually  by  gall-stones.  Infection  of  the  wall  of  the  gall- 
bladder leads  to  peritoneal  irritation,  a  fibrinous  exudate,  and  the  formation 
of  adhesions  which  often  involve  the  gall-bladder,  duodenum,  pyloric  end  of 
the  stomach,  right  border  of  the  omentum,  and  splenic  flexure  of  the  colon. 
Pain  and  tenderness  will  be  present  below  the  costal  border,  at  the  outer  border 
of  the  right  rectus  muscle.  If  the  gall-bladder  is  perforated,  an  abscess  will 
form  in  the  same  region,  and  will  give  the  signs  and  symptoms  of  localized 
peritonitis.  An  inflammatory  tumor  will  be  present  below  the  ribs  on  the 
right    side.      The    constitutional    symptoms    of    sepsis    will    be    more    or    less 


724  THE  PERITONEUM 

marked.  (See  Diseases  of  the  Biliary  Passages.  See,  also,  Subphrenic 
Abscess.) 

Localized  Peritonitis  Caused  by  Lesions  of  the  Pancreas. — Necrotic 
and  suppurative  lesions  of  the  pancreas  may  cause  a  local  peritonitis  behind  the 
stomach  in  the  lesser  peritoneal  sac.     (See  Diseases  of  the  Pancreas.) 

Subphrenic  Abscess. — Localized  peritonitis  of  the  lower  surface  of  the 
diaphragm  with  the  formation  of  a  walled-ofi"  abscess,  bounded  below  by  the 
liver,  or  by  the  liver  and  other  adjacent  viscera,  may  occur  as  a  part  of  the 
generalized  peritoneal  infection — notably  of  the  progressive  fibrino-purulent 
type — or  secondary  to  injuries  and  suppurative  or  perforative  lesions  of  cer- 
tain of  the  viscera,  notably  the  liver  and  gall-bladder,  stomach,  duodenum, 
transverse  colon,  vermiform  appendix,  spleen.  The  omentum  and  transverse 
colon  act,  in  many  cases,  by  forming  adhesions  with  the  abdominal  wall,  as 
a  dam  to  prevent  the  spread  of  infectious  material  upward  from  the  lower 
part  of  the  belly.  In  the  case  of  the  appendix,  pus  may  travel  upward  along 
the  colon  to  the  liver,  or  in  the  loose  tissues  behind  the  colon  to  the  right  border 
of  the  liver,  and  thence  infect  the  diaphragmatic  peritoneum.  On  account  of 
the  suspensory  ligameut  of  the  liver  which  separates  the  subdiaphragmatic 
space  into  two  parts,  lesions  of  the  appendix,  right  lobe  of  the  liver,  gall- 
bladder, and  right  kidney  are  apt  to  produce  an  abscess  on  the  right  side,  while 
lesions  of  the  stomach,  duodenum,  left  kidney,  pancreas,  and  spleen  usually 
infect  the  left  half  of  the  diaphragm. 

Infected  wounds  of  the  liver  and  suppurative  processes  of  all  kinds  in  the 
liver  or  biliary  passages  readily  reach  the  diaphragm  either  by  superficial 
extension  or  perforation  of  the  liver  tissue.  Slowly  perforative  lesions  of  the 
stomach  and  duodenum,  with  the  formation  of  limiting  adhesions,  may  spread 
to  the  upper  surface  of  the  liver,  usually  upon  the  left  side,  sometimes  upon 
the  right.  Ulcerative  lesions  of  the  lower  end  of  the  esophagus  and  empy- 
emata,  notably  of  the  putrid  variety,  may  penetrate  the  diaphragm  and  cause 
a  localized  infection  of  peritoneum.  Infectious  lesions  of  the  spleen,  the  kid- 
neys, the  pancreas,  may  all  give  rise  to  subdiaphragmatic  abscess,  as  may 
osteomyelitis  of  the  ribs  and  of  the  dorsal  vertebrae.  In  many  cases  the  pus 
of  these  abscesses  is  infected  with  the  saprophytic  germs  of  the  intestinal  tract, 
leading  to  the  formation  of  gas;  the  pus  will  have  a  putrid  odor  in  such  cases. 
An  important  and  frequent  complication  is  serous  or  purulent  pleuritis.  In- 
fection of  the  pericardium  is  not  very  rare. 

Symptoms  and  Diagnosis  of  Subphrenic  Abscess. — When  the  subphrenic 
abscess  occurs  as  the  immediate  result  of  a  wound  or  perforation  of  the  stomach 
or  duodenum,  or  exists  as  a  part  of  a  progressive  fibrino-purulent  peritonitis, 
the  signs  and  symptoms  of  acute  peritoneal  irritation — pain,  fever,  localized 
tenderness,  leucocytosis,  vomiting,  etc. — together  with  special  signs  and  symp- 
toms about  to  be  described,  usually  attract  the  surgeon's  attention  to  the  sub- 
diaphragmatic space.  When,  on  the  other  hand,  as  is  quite  often  the  case,  the 
abscess  develops  as  a  rather  late  complication  of  an  acute  localized  peritonitis 


LOCALIZED   TEKITONITIS  725 

days  or  weeks  after  an  operation  for  appendicitis  or  cholecystitis,  or  when  a 
gradual  extension  of  a  subacute  purulent  focus  in  some  neighboring  structure 
or  organ  infects  the  lower  surface  of  the  diaphragm,  the  abscess  often  develops 
insidiously  without  producing  any  marked  local  or  general  symptoms  to  indi- 
cate its  presence.  Its  existence  may  then  remain  unsuspected  for  a  good 
while. 

It  will  be  noticed  that  the  patient  is  not  doing  quite  well.  He  has  a  mod- 
erate rise  of  temperature  in  the  evening;  his  pulse  remains  a  little  rapid.  He 
may  sweat  at  night.  His  appetite  is  poor.  He  may  have  a  little  dyspnea. 
The  operation  wound,  if  such  be  present,  may  have  healed  or  may  be  slightly 
infected  or  sluggish.  Leucocytosis  of  a  moderate  grade  may  be  present  or 
the  count  may  be  normal.  There  is  no  abdominal  distention ;  the  belly  remains 
soft  and  flaccid.  Careful  inspection  will  show  a  greater  or  less  degree  of 
immobility  of  the  costal  margin  and  lower  ribs  on  one  or  other  side.  There 
may  be  neither  pain  nor  tenderness.  When  the  fluid  collection  has  become 
large  there  may  be  distinct  bulging  of  the  chest  wall. 

The  diagnosis  of  the  exact  condition  is,  in  some  cases,  easy  from  the  history 
and  the  physical  signs;  in  other  cases  it  will  be  quite  difficult.  In  these  cases 
the  use  of  an  aspirating  needle  is  justifiable,  and  of  great  aid  in  the  diagnosis. 
The  history  of  these  cases  will  usually  include  a  recent  injury  to  the  upper 
part  of  the  abdomen,  an  attack  of  appendicitis,  a  cholecystitis,  or  the  per- 
formance of  an  operation  for  one  of  these  conditions,  or  a  history  of  gastric 
or  duodenal  ulcer,  etc. 

The  physical  signs  vary  a  good  deal  in  different  cases,  and  are  sometimes 
puzzling.  In  a  typical  case  upon  the  right  side,  the  liver  is  displaced  down- 
ward, the  diaphragm  upward.  The  lower  border  of  the  liver  will  usually  be 
palpable  below  the  free  border  of  the  ribs.  The  liver  dullness  in  front  will 
be  increased  in  percussing  from  above  downward ;  there  will  be  pulmonary 
resonance  above,  then  dullness  or  flatness  to  the  lower  border  of  the  liver.  The 
line  of  dullness  above  will  be,  in  some  cases,  distinctly  arched  from  side  to 
side.  If,  as  is  usual  upon  the  right  side,  gas  is  present  as  well  as  pus,  there 
will  be  from  above  downward  pulmonary  resonance,  a  belt  of  tympanic  reso- 
nance more  or  less  broad,  and  below  that  flatness  to  the  lower  border  of  the 
liver.  In  some. cases,  if  the  purulent  collection  is  localized  in  the  posterior 
part  of  the  space  between  the  liver  and  diaphragm,  displacement  downward  of 
the  anterior  border  of  the  liver  may  not  occur.  Upon  auscultation  there  will 
be  normal  or  exaggerated  breathing  over  the  lung,  both  before  and  behind,  and 
a  sharp  boundary  line  below  which  breathing  is  absent.  If,  as  sometimes 
happens,  there  be  a  pleurisy  with  effusion  upon  the  same  side,  the  signs  pos- 
teriorly will  often  be  confusing. 

The  introduction  of  a  long  aspirating  needle  is  the  best  means  of  arriving 
at  a  diagnosis.  The  needle  may  be  introduced  into  the  area  giving  flatness  on 
percussion,  in  the  axillary  line  or  in  the  scapular  line,  or  even  in  front  in 
some  cases,  sometimes  at  the  point  of  greatest  tenderness.     If  the  first  puncture 


726  THE   PEKITONEUM 

fails  to  withdraw  pus,  the  needle  should  be  reinserted  in  several  different  situ- 
ations. As  the  needle  is  slowly  pushed  onward,  the  piston  of  the  springe  is 
drawn  out  a  little  from  time  to  time.  It  is  usually  possible  to  distinguish  the 
sense  of  resistance  produced  by  the  diaphragm.  If  there  be  pleurisy  with  effu- 
sion, the  needle  will  withdraw  serum  and,  at  a  deeper  level,  pus.  If  there  be 
empyema,  the  diagnosis  of  subphrenic  abscess  will  probably  not  be  made  until 
the  case  is  operated  upon,  when  the  upward  bulging  of  the  diaphragm  may  sug- 
gest abscess  of  the  liver,  subphrenic  abscess,  or  echinococcus  cyst.  The  appear- 
ance of  the  pns  in  abscess  of  the  liver  is  more  or  less  characteristic.  It  is  thick, 
dark  in  color,  resembling  chocolate ;  fragments  of  liver  tissue  are  to  be  recog- 
nized under  the  microscope.  The  pus  of  an  ordinary  empyema  is  usually 
creamy  and  yellow.  The  fluid  of  echinococcus  cysts,  if  not  infected,  is  clear, 
straw-colored ;  the  hooklets  can  be  discovered  under  the  microscope.  The  pres- 
ence of  gas,  with  pus  and  a  foul  odor,  will  indicate  subphrenic  abscess  or 
putrid  empyema. 

I  once  saw  a  fluid  accumulation  between  the  right  lobe  of  the  liver  and 
the  diaphragm  following  a  subcutaneous  injury  which  had  produced  a  moderate 
laceration  of  the  upper  surface  of  the  liver.  The  fluid  was  entirely  shut  off 
from  the  rest  of  the  belly  by  adhesions  between  the  anterior  border  of  the 
liver  and  the  abdominal  wall.  The  fluid  was  thin,  blood-stained,  and  con- 
tained numerous  flakes  and  masses  of  fibrin.  The  collection  was  entirely  asep- 
tic.    The  physical  signs  indicating  a  subphrenic  accumulation  were  present. 

Upon  the  left  side  subphrenic  abscess  follows  perforation  of  the  stomach 
and  duodenum  more  often  than  other  lesions.  When  these  perforations  are 
not  followed  by  general  infection  of  the  peritoneum  they  produce  an  abscess 
which  usually  gives  all  the  signs  of  acute  peritoneal  irritation,  followed  by 
marked  constitutional  symptoms  of  sepsis  and  all  the  local  signs  and  symptoms 
of  localized  purulent  peritonitis,  as  already  described.  There  will  often  be  a 
distinct  prominence  in  the  epigastrium,  over  which  the  abdominal  Avail  is  rigid 
and  tender.  The  liver  will  in  some  cases  be  displaced  downward,  and  may 
be  palpable.  The  heart  is  displaced  upward.  In  the  presence  of  such  signs 
and  symptoms  the  indications  for  opening  the  abdomen  are  quite  plain.  In 
other  cases  the  disease  may  develop  in  a  subacute  manner,  following  gradual 
perforations  of  the  stomach  and  duodenum  or  infectious  processes  of  the  pan- 
creas, kidney,  and  spleen,  or  one  of  the  other  conditions  already  mentioned. 

In  these  cases  the  physical  signs  may  be  important  aids  in  diagnosis,  but 
are  quite  often  confusing.  Abscesses  on  the  left  side,  arising,  as  they  do  in  a 
large  proportion  of  cases,  from  the  stomach  and  duodenum,  frequently  contain 
gas.  The  percussion  note  posteriorly  may,  as  upon  the  right  side,  exhibit  the 
following  qualities:  normal  resonance  over  the  lung  above,  tympanitic  reso- 
nance over  the  gas,  and  dullness  or  flatness  over  the  pus.  The  respiratory 
murmur  ceases  abruptly  below.  As  upon  the  right  side,  the  presence  of  a 
pleuritic  exudate  renders  the  physical  signs  uncertain.  The  aspirating  needle 
may  be  used  with  more  caution  than  upon  the  right  side  to  aid  the  diagnosis. 


CHK0N1C   PEKITONITIS  727 

In  the  presence  of  a  large  quantity  of  gas  and  pus  the  level  of  the  flatness  or 
dullness  may  change  upon  changing  the  position  of  the  patient.  The  stomach 
should  be  emptied  by  a  tube  when  making  this  examination  lest  its  fluid  and 
gaseous  contents  cause  confusion  of  the  signs. 

Chronic  Peritonitis. — Chronic  peritonitis  may  be  described  as  existing  in 
two  forms:  (1)  an  exudative  chronic  peritonitis;  (2)  chronic  peritonitis,  with 
the  production  of  adhesions. 

(1)  Chronic  Exudative  Peritonitis  (Vierordt,  A.  Fraenkel,  Lennan- 
der). — Chronic  exudative  peritonitis  is  identical  clinically  with  that  form  of 
tuberculous  peritonitis  accompanied  by  a  large  accumulation  of  serous  fluid 
in  the  belly.  The  resemblance  is  the  more  striking  because  nodular  masses 
in  the  omentum  are  said  to  form  in  chronic  exudative  peritonitis — a  striking 
character,  also,  of  this  form  of  tuberculous  peritonitis.  The  condition  appears, 
however,  to  be  a  well-recognized  one,  many  cases  having  been  described.  The 
disease  begins  without  apparent  cause,  usually  in  young  persons  of  the  female 
sex.  These  patients  become  pale  and  anemic;  they  lose  flesh  and  strength. 
Gradually  an  accumulation  of  fluid  occurs  in  the  abdomen,  usually  without 
pain  or  tenderness,  although  such  may  exist.  The  fluid  may  increase  to  a 
large  amount,  and  produce  pressure  symptoms  upon  the  diaphragm.  The 
bowels  may  be  constipated.  Nodular  masses  may  be  felt  in  the  omentum.  It 
is  necessary  to  exclude  tuberculous  peritonitis,  ascites  from  heart  disease,  or 
cirrhosis  of  the  liver,  and  serous  effusion  accompanying  malignant  disease  of 
the  abdominal  viscera.  (For  the  physical  signs,  see  Ascites.)  The  disease 
is  said  to  get  well  in  some  cases  without  surgical  treatment.  Upon  opening 
the  abdomen,  the  only  lesions  found  have  been  the  serous  effusion  and  the 
thickenings  of  the  omentum.  Evidences  of  tuberculosis  have  been  wanting 
and  inoculations  of  susceptible  animals  have  been  negative. 

(2)  Chronic  Peritonitis,  with  the  Production  of  Adhesions. — This 
form  of  peritonitis  may  follow  injuries  and  acute  inflammations  of  the  peri- 
toneum from  any  cause,  or  may  apparently  arise  as  an  independent  condition. 
Intraperitoneal  organs,  in  abnormal  situations  and  subjected  to  mechanical  irri- 
tation, portions  of  omentum  and  coils  of  intestine  retained  in  hernial  sacs,  quite 
regularly  are  the  seat  of  this  form  of  peritonitis.  It  may  be  a  localized  or 
general  process.  When  localized,  the  favorite  sites  of  the  lesion  are  in  those 
parts  of  the  belly  most  often  the  seat  of  acute  inflammatory  processes — the 
female  pelvic  peritoneum,  the  right  iliac  fossa,  the  region  of  the  duodenum, 
gall-bladder  and  pylorus,  the  root  of  the  mesentery,  the  flexures  of  the  colon. 
The  localization  renders  it  probable  that  in  most  instances  the  peritoneal  irri- 
tation has  originated  in  some  acute  or  chronic  inflammatory  focus.  The  lesion 
consists  in  the  formation  of  plaques,  masses,  and  bands  of  fibrous  connective 
tissue,  which  bind  the  peritoneal  surfaces  together  either  over  broad  areas  or 
through  the  medium  of  cords  or  bands.  In  some  cases  a  large  part  of  the 
peritoneal  space  is  obliterated,  in  others  dense  masses  of  fibrous  tissue  cement 
the  viscera  of  a  region  into  a  solid  mass.     (See  Pelvic  Peritonitis.)     Contrac- 


728  THE  PERITONEUM 

tion  of  the  new-formed  tissue,  as  time  goes  on,  causes  deformities  of  organs, 
interference  with  the  mobility  of  the  alimentary  tract,  disturbances  of  its 
function,  localized  diminution  of  its  caliber,  not  infrequently  sudden  and 
complete  obstruction,  and  furnishes  the  mechanical  factors  necessary  for  the 
production  of  torsions  of  the  gut,  obstruction  by  bands,  and  other  dangerous 
and  fatal  conditions.  As  stated,  chronic  adhesive  peritonitis  may  originate 
de  novo  at  any  time  of  life.  In  many  cases  it  follows  traumatisms  of  the  belly, 
either  accidental  wounds  or  operations  involving  the  peritoneum — notably  when 
extensive  handling  has  been  necessary.  The  majority  of  the  cases,  however, 
follow  acute  inflammatory  processes  in  the  abdomen  of  an  infectious  character 
irrespective  of  whether  they  have  been  operated  on  or  not.  It  may  be  due 
to  late  syphilis  of  the  gut. 

The  symptoms  cannot  be  described  categorically,  since  they  will  vary  with 
the  organs  or  structures  involved,  and  with  the  nature  of  the  mechanical  inter- 
ference with  their  function.  There  may  be  no  symptoms  for  years ;  suddenly 
the  bowel  may  become  twisted  upon  itself  or  kinked,  a  loop  of  gut  may  pass 
beneath  a  band  joining  two  adjacent  peritoneal  surfaces,  and  become  con- 
stricted or  kinked ;  in  either  case  the  symptoms  are  those  of  acute  intestinal 
obstruction.  Adhesions  in  the  neighborhood  of  the  gall-bladder  and  stomach 
may  cause  digestive  disturbances  and  pain  when  these  structures  are  thrown 
into  activity  by  the  ingestion  of  food.  Adhesions  about  the  colon  may  give 
rise  to  constipation  and  to  attacks  of  severe  colic.  Adhesions  in  the  female 
pelvis  give  rise  to  constipation  of  the  bowels,  to  displacements  and  deformities 
of  the  pelvic  viscera,  and  to  painful,  excessive,  or  irregular  menstruation. 

In  determining  upon  the  question  of  operative  relief  in  these  cases  the 
surgeon  must  be  guided  by  the  previous  history  of  injury  or  acute  inflamma- 
tion, by  the  nature  and  gravity  of  the  functional  disturbances,  by  the  location 
of  former  operative  scars,  and  by  the  nervous  condition  and  mental  attitude  of 
the  patient.  In  cases  of  acute  obstruction,  whether  or  not  immediately  or 
remotely  related  in  time  to  an  abdominal  operation,  no  delay  is  permissible ; 
a  postponement  of  operative  interference  for  a  few  hours  may  determine  the 
death  of  the  patient.  When  the  adhesions  cause  functional  disturbances  merely, 
the  patients  often  become  neurasthenic.  Some  of  these  cases  can  be  cured  or 
improved  by  operative  liberation  of  the  adherent  peritoneal  surfaces,  removal 
of  bands,  etc. ;  some  cannot.  In  a  good  many  cases  the  adhesions  reform  and 
the  symptoms  return.  I  recall  a  boy  who  had  intestinal  obstruction  from 
bands  following  an  operation  for  acute  appendicitis.  During  the  following 
two  years  he  had  intestinal  obstruction  three  times.  Following  the  fourth 
operation  he  died  of  paralysis  of  the  gut,  as  the  result  of  delay  in  presenting 
himself  for  treatment — the  operation  was  done  too  late. 

Tuberculous  Peritonitis. — In  acute  general  miliary  tuberculosis  miliary  tu- 
bercles are  found  in  the  serous  membranes,  including  the  peritoneum ;  the 
condition  is  without  surgical  interest.  As  a  localized  process,  tuberculous  peri- 
tonitis is  commonly  described  as  occurring  in  three  forms.     The  several  types 


TUBERCULOUS   PERITONITIS  729 

often  coexist,  or  develop  one  from  the  other.  Tuberculous  peritonitis  (1)  with 
abundant  serous  exudation;  (2)  with  the  formation  of  diffuse  infiltrations  and 
of  nodular  masses  of  tubercle  tissue  in  the  omentum,  the  mesentery,  in  the 
wall  of  the  gut,  and  on  the  abdominal  wall.  Contraction  of  these  infiltrations 
produces  shortening  of  the  mesentery  and  obliteration  of  its  peritoneal  folds ; 
the  omentum  is  converted  into  a  firm,  knobby  mass  of  tuberculous  nodules. 
Adhesions  may  occur  between  adjacent  peritoneal  surfaces,  with  partial  oblit- 
eration of  the  peritoneal  cavity.  (3)  With  the  formation  of  abundant  adhe- 
sions and  of  walled-off  collections  of  caseous  and  broken-down  fluid  tuberculous 
detritus.  The  peritoneal  cavity  is  commonly  obliterated.  The  first  form  is  the 
only  one  usually  amenable  to  successful  surgical  treatment.  The  lesion  con- 
sists in  an  abundant  serous  exudate  into  the  peritoneal  cavity.  In  some  cases 
the  picture  is  simply  that  of  ascites ;  no  masses  of  tuberculous  infiltration 
are  palpable  through  the  abdominal  wall ;  in  others,  a  combination  with  the 
second  type  exists.  The  peritoneal  surfaces  are  more  or  less  densely  studded 
with  submiliary  tubercles  and  larger  nodules  of  tubercle  tissue.  Tuberculous 
infiltration,  nodular  thickening,  and  shrinking  of  the  omentum  is  a  character- 
istic lesion.  The  omentum  is  converted  into  a  more  or  less  irregular  or  sausage- 
shaped  tumor  lying  transversely  across  the  abdomen,  usually  at  or  above  the 
level  of  the  umbilicus,  readily  palpable  through  the  abdominal  wall  as  a  firm 
mass,  somewhat  tender  and  slightly  movable.  There  may  be  palpable  masses 
in  the  mesentery,  in  the  wall  of  the  gut,  notably  in  the  cecum,  and  elsewhere. 
In  other  cases  there  will  be  no  fluid  in  the  belly ;  there  will  be  masses  of  tuber- 
culous infiltration  palpable  here  and  there,  but  upon  opening  the  abdomen  no 
fluid  will  be  found ;  the  peritoneal  cavity  may  be  obliterated  by  adhesions. 
In  other  and  rather  acute  cases  the  abdomen  is  nearly  dry;  the  peritoneal  sur- 
faces are  everywhere  reddened,  and  densely  studded  with  countless  tubercles 
varying  in  size  from  a  pin's  head  to  a  grain  of  rice.  In  the  third  form  the 
peritoneal  cavity  is  obliterated ;  the  intestines  are  firmly  adherent  in  an  inex- 
tricable mass.  Between  the  adherent  coils  here  and  there  in  the  abdomen  there 
are  collections  of  cheesy  material  and  tuberculous  pus ;  such  collections  may 
attain  a  large  size,  and  may  thus  simulate  cystic  tumors  of  organs. 

Symptoms  and  Diagnosis. — Tuberculous  peritonitis  is  rarely  a  primary 
affection,  but  is  usually  associated  with  tuberculosis  of  the  lungs,  the  lymph 
nodes,  the  bones,  the  joints,  the  kidney,  the  female  generative  apparatus 
(tubes).  In  not  a  few  cases  the  disease  appears  to  be  primary  in  the  wall 
of  the  gut,  notably  of  the  cecum  and  vermiform  appendix ;  these  cases  are 
easily  mistaken  for  malignant  disease  of  the  intestine.  The  existence  of  other 
tuberculous  lesions  or  characteristic  scars  is  often  an  important  aid  in  diag- 
nosis. The  patients  are  commonly  young  children  or  young  adults,  though 
older  individuals  are  not  exempt.  Women  are  more  often  affected  than  men. 
In  a  good  many  cases  the  disease  is  due  to  extension  from  the  uterus  and 
tubes,  occurring  in  virgins  or  parous  women.  Infection  may  immediately 
follow  labor.     The  course  is  chronic,  sometimes  with  acute  exacerbations.     In 


730  THE   PERITONEUM 

most  of  the  cases  there  is  a  history  of  gradual  loss  of  flesh  and  strength;  the 
patients  become  anemic.  There  may  be  a  moderate  daily  rise  of  temperature 
or  none.  Moderate  leucocytosis  may  be  present,  but  in  uncomplicated  cases 
the  polymorphonuclear  cells  will  not  be  relatively  increased.  When  there  is 
fever  the  pulse  will  be  accelerated.  When  serous  effusion  is  abundant,  dia- 
phragmatic breathing  may  be  interfered  with  and  the  breathing  rapid;  severe 
dyspnea  may  even  be  present  from  overdistention.  In  the  first  group  of  cases 
the  presence  of  free  fluid  in  the  belly  will  give  the  ordinary  signs — namely, 
the  abdomen  is  generally  and  evenly  distended,  the  umbilical  pit  is  often 
obliterated,  the  umbilicus  may  even  protrude,  dullness  or  flatness  on  percus- 
sion in  the  flanks,  tympanitic  resonance  in  front.  The  line  of  dullness  may 
be  made  to  vary  its  position  by  rolling  the  patient  on  his  side.  If  much  fluid 
is  present  and  the  intestines  are  held  away  from  the  abdominal  wall  by  a  con- 
tracted infiltrated  mesentery,  there  may  be  flatness  on  percussion  in  front, 
simulating  a  large  ovarian  cyst.  An  encapsulated  collection  of  tuberculous 
pus  may  give  rise  to  a  similar  impression.  When  the  fluid  is  serous  and  free, 
if  one  hand  is  placed  upon  the  flank  while  the  opposite  side  of  the  abdomen 
is  sharply  tapped,  a  sensation  of  a  fluid  wave  will  be  transmitted  across  the 
abdomen.  The  abdominal  wall  is  soft,  the  extreme  tenderness  and  rigidity 
of  acute  peritonitis  are  absent.  There  may  be  moderate  tenderness  if  nodular 
masses  are  present  in  the  abdomen.  The  pain  complained  of  by  these  patients 
is  not  usually  continuous  nor  very  severe  unless  the  functions  of  the  gut  are 
interfered  with  by  adhesions.     Attacks  of  colicky  pain,  and  even  total  ob- 


Fig.  256. — Tuberculous  Peritonitis  with  Abundant  Serous  Exudation  in  a  Child. 
(New  York  Hospital  collection.) 

struction,  may  occur  in  such  cases.  The  function  of  the  alimentary  canal  may 
be  interfered  with  in  various  ways.  There  may  be  exhausting  diarrhea.  If 
the  motions  of  the  intestine  are  interfered  with  by  adhesions  or  contractions 
of  the  mesentery  there  may  be  marked  constipation — even,  as  stated,  total 
obstruction.  The  serous  accumulations  may  be  differentiated  from  cirrhosis  of 
the  liver  by  the  age  of  the  patient,  and  the  absence  of  an  alcoholic  history.  In 
cirrhosis,  enlargement  of  the  spleen  is  usually  present.  There  is  often  jaun- 
dice, a  change  in  the  size  of  the  liver,  vomiting  of  blood,  nosebleed,  hemor- 
rhoids,  enlargement  of  the  superficial  veins  of  the   abdomen,   gastritis,   etc. 


ASEPTIC   PERITONITIS  731 

The  ascites  accompanying  valvular  disease  of  the  heart  is  accompanied  by 
valvular  murmurs,  changes  in  quality  of  the  heart  sounds  and  in  the  size 
of  the  heart.  The  serous  and  bloody  peritoneal  effusions  accompanying  some 
cases  of  carcinoma  and  sarcoma,  with  invasion  of  the  peritoneum,  are  usually 
accompanied  by  a  more  profound  cachexia ;  a  large  parent  tumor  is  usually 
discoverable.  The  age  of  these  patients  is  commonly  advanced.  There  will 
be  cases  where  the  surgeon  will  be  puzzled  until  the  abdomen  is  opened.  Those 
cases  arising  from  the  tubes  will  show  inflammatory  thickening  and  deformity 
of  these  structures  on  bimanual  palpation.  Perhaps  the  most  puzzling  cases 
of  tuberculous  peritonitis  are  those  arising  from  tuberculous  infiltration  of  the 
wall  of  the  cecum  and  in  the  vermiform  appendix.  The  condition,  in  some 
cases,  will  be  mistaken  for  chronic  appendicitis,  with  the  production  of  ad- 
hesions. In  other  cases  the  infiltrated  cecum  forms  a  large,  nodular,  hard 
tumor  in  the  right  iliac  fossa,  which  closely  simulates  a  malignant  growth. 
No  positive  diagnosis  is  apt  to  be  made  in  these  cases  in  the  absence  of  other 
evidences  of  tuberculosis  until  the  abdomen  is  opened.  When  the  tuberculous 
ulceration  and  perforation  of  the  gut  occur,  acute  progressive  purulent  peri- 
tonitis, or  a  localized  peritonitis  surrounding  an  abscess  cavity,  will  give  the 
signs  and  symptoms  of  the  complicating  infection  in  addition  to  those  already 
present.  I  have  happened  to  operate  on  a  number  of  these  cases ;  the  situation 
is  gloomy  as  far  as  eventual  cure  is  concerned.  A  tuberculous  artificial  anus 
is  quite  apt  to  follow  resection  of  the  tuberculous  gut. 

Aseptic  Peritonitis. — The  peritoneum  reacts  promptly  to  all  forms  of  me- 
chanical and  chemical  irritation  by  throwing  out  an  exudate  which  may  be 
serous,  fibrinous,  or  consist  of  serum  stained  with  blood;  so  long  as  no  active 
germs  are  present,  pus  is  not  formed.  The  end  result  of  such  irritations  is 
the  production  of  adhesions;  these  may  be  absorbed  after  a  time  or  be  per- 
manent. Aseptic  peritonitis  occurs  as  the  result  of  aseptic  injuries  to  the 
peritoneum,  whether  accidental  or  made  during  the  performance  of  surgical 
operations.  The  irritation  produced  by  aseptic  fluids — bile,  blood,  the  con- 
tents of  cysts,  small  quantities  of  aseptic  urine — has  a  similar  effect.  Portions 
of  tissue  deprived  of  nourishment  by  ligatures,  cauterizations,  or  crushing, 
cause  the  formation  of  adhesions.  Cysts  with  twisted  pedicles,  strangulations 
of  portions  of  the  intestine  before  the  gut  has  lost  its  vitality,  volvulus,  intus- 
susception, and  numerous  other  like  conditions,  all  may  produce  a  serous  or 
fibrinous  exudate,  assuming  that  no  bacteria  are  present.  The  various  chem- 
ical antiseptics  act  in  a  similar  manner.  Aseptic  foreign  bodies — drainage- 
tubes,  gauze  packings,  ligatures — all  are  rapidly  surrounded  by  a  fibrous  exu- 
date and  adhesions,  when  left  in  the  peritoneum.  The  symptoms  of  aseptic 
peritonitis  may  be  quite  marked ;  there  may  be  pain,  abdominal  distention  and 
rigidity,  vomiting,  even  paralysis  of  the  gut.  Septic  symptoms  are  wanting. 
The  process  usually  ends  in  resolution  and  recovery  so  long  as  the  exudate 
remains  free  from  pyogenic  germs.  As  stated,  the  adhesions  formed  may  be 
absorbed  or  remain  indefinitely. 


732  THE   PERITONEUM 

Injuries  of  the  Peritoneum  and  Abdominal  Contents. — The  dangers  of  in- 
juries of  the  abdomen  are  chiefly  two:  bleeding,  and  peritonitis  from  a  wound 
or  rupture  of  one  of  the  hollow  organs  of  the  belly  and  the  escape  of  infectious 
material  into  the  peritoneal  cavity.  Intra-abdominal  conditions  are  favorable 
for  the  continuance  of  bleeding.  The  blood-vessels  of  the  omentum,  mesentery, 
stomach,  and  intestine,  as  well  as  the  great  vessels  of  the  abdomen,  lie  in 
loose  tissues ;  the  blood  can  flow  freely  into  the  cavity  of  the  peritoneum  with- 
out resistance,  and  fatal  hemorrhage  may  take  place  from  a  surprisingly  small 
source.  Wounds  and  ruptures  of  the  solid  organs,  liver,  and  spleen  bleed  very 
rapidly,  as  a  rule.  Wounds  and  ruptures  of  the  kidney  vary  a  good  deal  in 
this  respect,  dependent  upon  the  direction  and  extent  of  the  injury.  Wounds 
of  omentum  may  rarely  cause  fatal  hemorrhage.  I  recall  the  case  of  a  young 
man  who  was  stabbed  with  a  penknife  in  the  lower  epigastrium,  and  who 
developed  the  symptoms  of  abdominal  hemorrhage ;  upon  opening  the  abdomen, 
but  little  free  blood  was  found  in  the  belly.  The  wound  in  the  abdominal  wall 
corresponded  to  the  situation  of  the  gastrocolic  omentum.  The  bleeding  had 
taken  place  into  the  substance  of  the  omentum,  and  the  blood  had  infiltrated 
and  dissected  its  way  widely  beneath  the  peritoneum.  The  gastrocolic  omen- 
tum, the  transverse  colon,  and  the  great  omentum  were  greatly  swollen,  infil- 
trated with  blood,  and  converted  into  a  spongy  mass  which  bled  freely  wherever 
handled.  It  was  impossible  to  determine  the  situation  of  the  wounded  vessel. 
The  gastroepiploic  arteries  were  secured,  but  the  bleeding  continued  in  spite 
of  the  ligation  of  tissues  en  masse  and  other  devices,  until  the  patient's  death 
the  following  day.  Many  wounds  of  the  omentum  bleed  only  moderately,  and 
it  is  exceptional  that  death  is  due  solely  to  this  cause.  In  general  it  may  be 
said  that  dangerous  intra-abdominal  bleeding  occurs  most  often  from  wounds 
of  the  solid  organs  and  from  the  mesentery  rather  than  from  wounds  of  the 
wall  of  the  stomach  and  intestine.  The  great  vessels  of  the  belly  and  their 
named  branches  will,  if  wounded,  cause  fatal  bleeding  so  rapidly  that  they 
rarely  come  under  surgical  treatment. 

A  very  large  proportion  of  penetrating  wounds  of  the  abdomen,  whether 
they  are  incised,  punctured,  or  gunshot  wounds,  injure  the  abdominal  viscera. 
The  alimentary  canal  is  more  often  injured  than  other  organs.  The  escape 
of  intestinal  contents  is  regularly  followed  by  fatal  peritonitis.  In  some 
wounds  of  the  intestine,  whether  punctured  or  gunshot,  if  the  wound  be  not 
very  large,  prolapse  of  the  mucous  membrane  of  the  gut  may  temporarily 
and  rarely,  even  permanently,  occlude  the  opening  so  that  only  a  localized  adhe- 
sive peritonitis  or  a  localized  abscess  results.  Such  an  occurrence  is  exceptional. 
In  the  larger  number  of  cases  escape  of  intestinal  contents  takes  place,  and 
diffuse  purulent  peritonitis  is  developed  in  a  few  hours.  Some  variations  occur 
in  the  rapidity  with  which  the  signs  and  symptoms  of  peritonitis  appear,  de- 
pending upon  the  part  of  the  alimentary  tract  wounded  and  the  amount  and 
character  of  its  contents  at  the  time  of  its  injury.  The  contents  of  the  small 
intestine  (jejunum  and  ileum)  are  always  fluid  and  always  highly  infectious; 


PENETRATING   WOUNDS    OF   THE    ABDOMEN  733 

a  rapid  leakage  and  a  virulent  peritonitis  are  t<»  be  expected  after  wounds  of 
this  part  of  the  gut.     The  stomach,  on  the  other  hand,  may  be  full  or  empty 

at  time  of  wounding;  hence,  a  rapid  leakage  and  an  active  peritonitis  will 
occur  in  some  cases,  a  tardy  and  perhaps  less  violent  inflammation  in  others-. 
The  prognosis  of  untreated  wounds  of  the  stomach  is  in  general  very  bad.  Tli<- 
escape  of  the  contents  of  the  duodenum  is  not,  in  my  experience,  followed  by 
so  virulent  a  peritonitis  as  occurs  from  wounds  of  the  ileum.  The  contents 
of  the  colon  are  sometimes  fluid,  sometimes  solid;  leakage  may  be  rapid  or 
slow.  Wounds  of  the  extraperitoneal  portions  of  the  ascending  and  descending 
colon  may  be  followed  by  slow  leakage  and  the  gradual  formation  of  an  abscess 
or  phlegmonous  inflammation  of  the  loin.  The  abscess  cavity  will  contain  pus, 
fecal  matter,  and  gas.  It  is  to  be  remembered  in  regard  to  the  prognosis  of 
penetrating  wounds  of  the  abdomen  that  sharp  instruments  may  partly  divide 
the  coats  of  the  gut,  and  that  blunt  instruments  may  contuse  the  wall  of  the 
intestine.  In  either  case  sloughing  and  perforation  may  occur  many  days  after 
the  injury.  In  open  wounds  of  the  belly  a  third  risk  is  also  present,  namely, 
the  infection  of  the  peritoneum  by  the  instrument  which  created  the  wound, 
or  subsequently  by  the  clothing,  by  germs  upon  the  skin,  by  unclean  hands, 
instruments,  etc.  The  abdominal  wounds  made  by  the  surgeon  are  protected 
as  far  as  may  be  from  infection.  Accidental  wounds  are  exposed  to  infection 
by  injudicious  handling  and  exploration  without  due  aseptic  precautions.  The 
peritoneum  is,  as  stated,  quite  resistant  to  infection,  as  is  abundantly  shown. 
by  the  behavior  of  operation  wounds.  The  external  wound  may  become  in- 
fected and  the  peritoneum  escape  if  closed  off  mechanically  or  by  a  fibrinous 
exudate.  Once  infected,  the  conditions  are  as  favorable  for  the  spread  of  the 
process  after  traumatic  as  after  pathological  lesions. 

Penetrating  Wtounds  of  the  Abdomen — Symptoms  and  Diagnosis 
(see  also  Wounds  of  the  Abdominal  Wall). — As  a  matter  of  practical  detail, 
it  may  be  stated  that  the  examination,  exploration,  and  treatment  of  pene- 
trating wounds  of  the  belly,  or  of  those  in  which  penetration  is  suspected  or 
possible,  should  be  undertaken,  even  at  the  risk  of  some  delay,  with  all  the 
careful  preparation  which  precedes  the  most  elaborate  abdominal  operation. 
Only  in  this  manner  can  danger  from  infection  from  without  be  avoided,  and 
only  thus  can  the  often  unexpected  dangers  and  difficulties  of  a  serious  visceral 
injury  be  met  and  overcome.  All  preliminary  probing  and  fingering  are  to 
be  condemned  as  unnecessary,  useless,  and  dangerous.  When  a  wound  is 
known  to  penetrate  the  belly,  the  less  the  patient  is  moved  about  the  better. 
In  carrying  and  transporting  such  an  individual,  the  utmost  gentleness  possible 
under  existing  conditions  is  imperative.  Necessity  and  occasion  may  arise 
when  these  precepts  cannot  be  carried  out.  The  surgeon  must  then  do  the  best 
he  can  with  the  means  at  hand,  and  much  may  be  done  if  only  cleanliness 
can  be  maintained.  Incised  wounds  of  the  peritoneum,  suitably  placed,  are 
often  followed  by  prolapse  of  the  viscera,  most  often  the  omentum,  which  may 
find  its  way  through  a  very  small  wound,  and  regularly,  also,  the  intestine  it" 


734  THE   PEKITOKEUM 

the  wound  is  larger.  These  structures,  if  exposed  to  the  air  for  a  few  hours, 
become  covered  with  fibrin  and  assume  a  dirty  gray  color.  The  intestine  is 
readily  recognized,  and  the  omentum  also  from  the  characteristic  lobulated 
fat  which  it  contains  and  the  delicate  structure  of  its  connective-tissue  frame- 
work. Only  rarely  could  a  projecting  tab  of  subcutaneous  fat  be  mistaken 
for  it.  If  it  be  omentum,  gentle  traction  will  draw  it  farther  out  of  the 
abdomen.  The  solid  viscera  only  rarely  protrude  through  an  accidental  wound. 
The  liver  and  spleen  are  readily  recognized  by  their  consistence,  color,  shape, 
and  anatomical  situation.  Occasionally,  as  the  result  of  an  incised  wound,  a 
considerable  quantity  of  small  intestine  may  escape  from  the  belly,  and  such 
intestine  may  be  extensively  torn,  contused,  or  cut.  The  diagnosis  is  to  be 
made  by  inspection.     I  recently  operated  upon  such  a  case. 

A  man  stabbed  his  wife  in  the  abdomen  with  a  carving  knife,  turning  the  blade 
as  he  withdrew  it.  A  wound  about  two  and  a  half  inches  in  length  and  angular 
in  shape  was  produced  to  the  right  of  the  umbilicus  which  severed  about  two  thirds 
of  the  belly  of  the  right  rectus  muscle.  The  woman  was  brought  to  the  hospital 
very  soon  after  the  wounding  and  taken  at  once  to  the  operating  room,  less  than 
forty  minutes  from  the  receipt  of  the  injury.  The  symptoms  of  shock  were  mod- 
erate; she  had  vomited  once.  Upon  removing  her  clothing  a  large  mass  of  small 
intestine  was  found  outside  the  abdomen,  smeared  with  intestinal  contents  and 
much  blood.  The  prolapsed  coils  measured  about  five  feet  in  length.  There  were  five 
incised  wounds  of  the  gut — three  of  them  transverse  cuts  about  an  inch  in  length. 
Two  almost  completely  severed  the  intestine.  There  were  two  incised  wounds  of 
the  mesentery.  The  intestines  were  washed,  the  bleeding  from  the  mesentery  con- 
trolled, the  intestines  sutured  and  again  washed.  Upon  exploring  the  interior  of 
the  belly  no  further  injuries  were  found,  nor  was  the  peritoneum  soiled.  The  in- 
testine was  returned  to  the  belly  and  the  external  wound  partly  sutured.  The 
patient  made  a  prompt  recovery. 

From  some  wounds  of  the  belly  which  open  the  hollow  viscera  a  discharge 
may  take  place  of  a  character  indicating  the  organ  wounded ;  thus,  the  escape 
of  gas  or  of  intestinal  contents  would  indicate  positively  a  wound  of  the  stom- 
ach or  intestine ;  an  escape  of  bile,  a  wound  of  the  gall-bladder,  the  bile  ducts, 
the  liver,  possibly  the  duodenum ;  an  escape  of  urine,  a  wound  of  the  urinary 
bladder,  ureter,  or  kidney,  according  to  the  anatomical  site  of  the  wound. 
While  such  signs  are  positive  and  reliable  when  present,  their  occurrence  is 
not  constant,  and  their  appearance  is  not  to  be  awaited  as  a  means  of  diagnosis. 

When,  from  the  history  of  the  case  and  the  appearance  of  the  external 
wound,  it  seems  doubtful  whether  the  peritoneum  has  been  opened  or  not,  the 
safest  and  surest  means  of  diagnosis  is  to  explore  the  wound  with  the  most 
careful  aseptic  precautions.  If  retraction  of  the  wound  edges  and  the  intro- 
duction of  a  sterile  gloved  finger  still  leaves  the  matter  in  doubt,  the  patient 
should  be  put  under  a  general  anesthetic  and  the  wound  enlarged  sufficiently 
to  settle  the  question  of  penetration.     If  penetration  exists,  the  presence  of 


PENETRATING  WOUNDS  OF  THE  ABDOMEN        735 

blood,  intestinal  contents,  gas,  bile,  or  other  material  will  indicate  injury  of  the 
blood-vessels  or  viscera,  as  the  case  may  be.  If  no  foreign  material  is  found, 
the  structures  underlying  the  wound  in  the  belly  wall  should  be  carefully  in- 
spected. If  no  injury  of  the  viscera  be  discovered  and  no  symptoms  have 
previously  existed  indicating  such,  the  wound  may  be  closed,  with  such  drain- 
age as  seems  necessary  for  the  given  case. 

Stab  and  Gunshot  Wounds  of  the  Abdomen. — The  diagnosis  of  penetration 
and  of  visceral  injury  can  often  be  made  in  the  case  of  incised  wounds  of  the 
abdominal  wall  upon  inspection.  Such  is  less  often  the  case  in  stab  and  gun- 
shot wounds.  In  these  latter  we  are  often  able  to  infer  penetration,  intra- 
abdominal hemorrhage,  or  visceral  injury.  From  the  situation  and  direction 
of  the  wound  or  wounds,  from  the  character  of  the  weapon  or  missile,  from 
powder  marks  upon  the  skin  or  clothing  indicating  close  range  and  probable 
penetration,  from  the  degree  of  violence  used,  and  from  local  and  general 
symptoms  exhibited  by  the  patient.  We  have  already  described  the  symptoms 
of  abdominal  shock.  Such  symptoms  are  usually  marked  after  severe  contu- 
sions of  the  abdomen,  notably  those  accompanied  by  rupture  of  the  viscera. 
They  are  commonly  present  after  gunshot  wounds,  especially  after  wounds 
of  the  stomach.  They  have  been  absent  in  several  stab  wounds  I  have  seen 
with  injury  to  the  liver,  intestine,  kidney,  and  other  organs,  though  in  other 
similar  cases  they  have  been  present.  The  presence  of  shock  bespeaks  the  prob- 
able existence  of  serious  intra-abdominal  injury. 

Symptoms  of  Intra-abdominal  Bleeding. — The  symptoms  of  intra-abdominal 
bleeding  are  increasing  pallor  of  the  skin  and  mucous  membranes,  a  progressive 
increase  in  the  pulse  rate.  The  radial  pulse  becomes  more  and  more  feeble  and 
compressible ;  coldness  of  the  extremities,  sometimes  a  cold  and  clammy  per- 
spiration, restlessness,  thirst,  anxiety,  air-hunger,  syncope,  sometimes  vomiting. 
Locally,  there  is  severe  abdominal  pain  and  tenderness,  sometimes  localized  or 
general  rigidity,  rarely  noticeable  distention.  There  may  be  dullness  in  the 
flanks  and  other  signs  of  free  fluid  in  the  belly  if  the  hemorrhage  is  very  large. 
When  the  blood  collects  in  the  region  of  the  spleen,  below  the  right  lobe  of  the 
liver,  in  the  pelvis,  in  the  lesser  sac,  or  behind  the  peritoneum,  there  may  be 
the  formation  of  a  more  or  less  defined  palpable  mass  or  sense  of  resistance 
in  the  abdomen,  dull  or  flat  upon  percussion.  Such  a  mass  may  slowly  or 
rapidly  increase  in  size  for  several  days  if  the  patient  survives  and  is  not 
operated  upon.  As  the  blood  partly  coagulates  or  is  shut  in  by  adhesions,  the 
boundaries  of  the  tumor  become  more  distinct.  Such  signs  are  more  often 
observed  after  subcutaneous  injuries  than  after  stab  and  gunshot  wounds,  since 
the  latter  are  more  commonly  subjected  to  early  operation. 

Signs  and  Symptoms  of  Injury  to  the  Alimentary  Canal. — The  signs  and 
symptoms  of  injury  to  the  alimentary  canal  are  by  no  means  so  definite  at 
first  unless  stomach  or  intestinal  contents  or  gas  escape  from  the  wound.  In 
wounds  of  stomach  and  duodenum,  accompanied  by  the  escape  of  gas  from 
the  external  wound,  such  gas  will  be  odorless,  or  at  least  have  no  fecal  odor. 


736  THE   PEEITONEUM 

In  subcutaneous  perforations,  whether  traumatic  or  due  to  ulcerative  processes, 
we  may,  upon  opening  the  abdomen,  observe  the  escape  of  odorless  or  of  stink- 
ing gas,  suggesting  the  stomach  or  duodenum  or  the  large  and  small  intestine 
as  a  source,  respectively.  Evidences  of  peritoneal  irritation,  due  to  the  escape 
of  intestinal  contents,  may  not  appear  for  a  number  of  hours.  Early  signs 
and  symptoms  are  vomiting,  sometimes  of  blood,  rarely  passage  of  blood  per 
rectum,  localized  abdominal  pain,  tenderness,  and  muscular  rigidity.  During 
the  early  hours  the  abdominal  wall  is  usually  retracted,  flat,  or  concave  (the 
scaphoid  abdomen),  and  of  boardlike  hardness.  After  six,  eight,  or  twelve 
hours  the  signs  and  symptoms  become  those  of  diffuse  purulent  peritonitis.  As 
a  matter  of  experience  it  is  observed  that  cases  of  intestinal  wounds  with  ex- 
travasation recover  in  a  considerable  proportion  of  cases,  if  operated  upon 
early,  during  the  first  six  to  eight  hours ;  after  that  time  the  prognosis  becomes 
much  worse.  When  doubt  exists,  in  a  penetrating  wound  of  the  belly,  as  to 
the  existence  of  visceral  lesions,  early  operative  exploration  of  the  abdomen 
is  the  safest  and  best  diagnostic  measure. 

Some  General  and  Special  Data. — Some  general  and  special  facts  are 
of  interest.  Wounds  in  the  epigastrium  occur  without  wounds  of  the  viscera 
more  often  than  those  in  the  lower  part  of  the  belly ;  this  is  especially  true 
of  stabs  and  punctures  made  with  rather  dull  instruments ;  the  stomach  or 
transverse  colon  may  be  pushed  aside  and  not  perforated ;  the  same  may  be 
true  when  the  abdomen  is  penetrated  by  falling  on  a  stake,  an  iron  picket,  or 
the  like,  or  when  the  abdomen  is  penetrated  by  the  horn  of  a  bull.  It  should 
be  borne  in  mind  that  the  stomach  or  gut  may  be  contused,  and  subsequently 
slough  and  perforate  many  days  later — as  late  as  a  fortnight,  for  example. 
Such  late  perforations  are,  however,  much  more  frequent  as  the  result  of  sub- 
cutaneous injuries.  Wounds  of  the  stomach  or  the  gut  made  by  stabs  are 
sometimes  single,  sometimes  multiple.  Those  made  by  bullets  are  rarely  single, 
usually  multiple ;  four,  eight,  twelve,  sixteen  perforations  are  frequently  ob- 
served. There  are  usually  two  openings  in  each  wounded  coil  or  in  the  stom- 
ach, as  the  case  may  be — one  where  the  bullet  entered,  one  where  it  came  out. 
Revolver  bullets,  and  even  high-powdered  rifle  bullets  with  the  full  mantle  and 
of  small  caliber,  may,  as  stated  under  Gunshot  Wounds,  pass  entirely  through 
the  abdomen  and  wound  no  important  viscus. 

The  anatomical  site  of  a  stab  wound  and  the  direction  of  the  wound  canal, 
together  with  a  knowledge  of  the  length  of  the  instrument,  permits  a  probable 
diagnosis  as  to  the  organs  penetrated.  This  is  true  to  a  much  smaller  extent 
in  the  case  of  bullet  wounds,  even  though  they  have  passed  directly  through 
the  body.  A  certain  number  of  gunshot  wounds  of  the  abdomen  also  pass 
through  the  pleura,  lung,  and  diaphragm.  In  these  cases  air  may  enter  the 
abdomen  from  the  chest,  and  cause  abdominal  distention  and  absence  of  liver 
dullness.  Stomach  or  intestinal  contents  may  also  pass  into  the  pleural  cavity 
and  cause  death  from  septic  pleuritis,  although  the  intestinal  wounds  have  been 
closed  and  peritonitis  avoided. 


.  PENETRATING   WOUNDS    OF   THE    ABDOMEN  737 

The  gravity  of  the  injuries  produced  by  gunshot  wounds  involving  both 
the  thorax  and  the  abdomen  varies  much,  depending  chiefly  upon  the  character 
of  the  visceral  injuries.  The  two  following  histories  serve  to  indicate  the 
very  different  results  which  may  follow  shots  fired  under  like  circumstances : 

Gunshot  Wounds  of  Pleura,  Lung,  Diaphragm,  Intestine,  and  Kidney. — 
Case  I. — G.  R.,  a  well-nourished,  vigorous-looking  man  in  the  prime  of  life, 
was  admitted  to  the  New  York  Hospital  on  the  afternoon  of  November  24,  1904. 
Twenty  minutes  before  admission  he  had  been  shot  in  the  chest  with  a  .32  caliber 
revolver  at  close  range.  On  admission  his  face  was  pale  and  anxious.  Extremities 
cold.  Pulse  rapid  and  feeble.  Rectal  temperature,  99.6°.  Respiration,  28,  and 
labored.  There  was  a  bullet  wound  in  the  seventh  intercostal  space  on  the  left 
side,  in  the  anterior  axillary  line.  There  was  no  hemoptysis  nor  external  bleeding. 
The  abdomen  was  moderately  distended,  tympanitic,  and  rigid.  There  was  absence 
of  liver  dullness.  The  rigidity  was  most  marked  in  the  left  hypochondrium.  The 
patient  had  vomited  partly  digested  food.  I  saw  the  patient  a  few  minutes  after 
his  admission,  and  operated  upon  him  under  ether  less  than  an  hour  after  the 
shooting.  Abdomen  opened  along  outer  edge  of  left  rectus  muscle.  Free  blood,  air, 
and  a  small  amount  of  intestinal  contents  in  the  abdominal  cavity.  Upon  retract- 
ing the  wound  edges  and  pushing  aside  the  stomach  a  perforation  could  be  seen  in 
the  diaphragm  about  four  inches  from  the  middle  line,  through  which  air  and  blood 
rushed  in  and  out  during  respiration.  There  was  a  single  contused  wound  of  the 
transverse  colon  which  had  not  opened  the  gut.  There  were  two  perforations  in 
the  jejunum  about  seven  inches  from  its  junction  with  the  duodenum.  The  wounds 
in  the  gut  were  sutured  and  the  abdomen  washed.  Efforts  to  close  the  wound  in 
the  diaphragm  had  to  be  desisted  from  on  account  of  the  bad  condition  of  the 
patient.  No  active  bleeding  into  the  belly,  other  than  from  the  diaphragm,  was 
observed.  Stimulation,  drainage,  closure  of  abdominal  wound.  Patient  rallied 
from  shock,  but  had  a  gradually  increasing  abdominal  distention.  Continued 
vomiting,  finally,  dark  brown  in  color  and  with  a  foul  odor.  There  was  marked 
dyspnea  and  the  physical  signs  of  hemopneumothorax  on  the  left  side.  On 
November  25th  the  urine  contained  a  moderate  amount  of  blood.  His  temperature 
and  pulse  gradually  rose,  and  he  died  November  26th  at  9.30  a.:m.  The  autopsy 
showed,  in  addition  to  the  injuries  described,  a  perforating  wound  of  the  lower 
lobe  of  the  left  lung  and  a  lacerated  wound  of  the  lower  pole  of  the  left  kidney. 
There  was  a  moderate  amount  of  blood-stained  fluid  in  the  peritoneal  cavity.  The 
intestinal  wounds  were  water-tight. 

The  second  case  was  a  young  woman  who,  on  August  19,  1905,  was  shot  with  a 
.32  caliber  pistol  in  the  right  side  of  the  chest  at  close  range.  She  was  brought 
to  the  hospital,  where  I  saw  her  with  Dr.  P.  R.  Bolton,  to  Avhose  service  the  case 
was  admitted.  The  patient  was  pale  and  suffering  from  moderate  shock.  There 
was  a  bullet  wound  in  the  eighth  intercostal  space  in  the  posterior  axillary  line  on 
the  right  side  of  the  chest.  Beneath  the  wound  in  the  skin  there  was  a  consid- 
erable hematoma  extending  over  an  area  about  two  and  a  half  inches  in  diameter. 
There  was  normal  breathing  over  that  side  of  the  chest.  A  few  fine  rales  could 
be  heard  posteriorly  at  the  lower  border  of  the  lung.  Aside  from  a  moderate  rise 
of  temperature  lasting  for  ten  days  and  pretty  severe  pain  referred  to  the  right  side 
48 


738  THE   PEKITONETJM 

in  the  region  of  the  wound,  there  were  no  marked  symptoms  of  any  kind.  At 
the  end  of  ten  days  the  bullet  was  felt  beneath  the  skin  in  the  eighth  intercostal 
space,  between  the  scapular  and  posterior  axillary  line  on  the  left  side,  and  was 
found,  upon  incision,  embedded  in  the  intercostal  muscles  at  that  point.  The 
patient  made  a  good  recovery.  While  the  track  of  the  bullet  in  this  case  can  only 
be  surmised,  it  seems  possible  that  it  penetrated  the  right  pleura  and  diaphragm, 
the  right  lobe  of  the  liver,  and  emerged  through  the  diaphragm  and  left  pleura 
to  the  point  where  it  was  found.  It  may,  of  course,  have  been  a  contour  shot,  but 
no  line  of  pain  and  tenderness  across  the  back  existed  to  indicate  such  a  course. 

A  bullet  passing  horizontally  across  the  belly  from  flank  to  flank,  or  one 
passing  directly  backward  in  the  center  of  the  abdomen  near  the  umbilicus, 
is  more  apt  to  cause  multiple  injuries  than  one  taking  an  oblique  course  from 
above  downward  or  from  before  backward,  or  one  passing  from  before  back- 
ward in  the  epigastrium.  Bullets  are  much  more  apt  to  injure  a  number  of 
different  organs  than  are  stab  wounds.  The  character  of  the  effects  upon 
the  tissues  produced  by  different  types  of  weapons  and  bullets  have  been  suffi- 
ciently described  under  Gunshot  Wounds.  Here  it  may  be  added  that  the 
explosive  effect  upon  hollow  organs  filled  with  fluid  or  semifluid  material,  and 
upon  solid  organs,  is  scarcely  observed  after  revolver  shots,  such  as  are  ordi- 
narily encountered  in  the  hospitals  in  the  city  of  New  York.  The  wounds  are 
made  with  .22,  .32,  and  .38  caliber  pistols,  rarely  larger.  The  initial  velocity 
is  not  very  high. 

The  Chinese  in  the  murderous  affrays  so  common  of  late  between  their 
factions  in  this  city  use  heavy  revolvers,  .44  Colt.  The  injuries  produced,  as 
seen  in  the  Hudson  Street  Hospital,  are  very  severe,  and  often  fatal.  If  a 
bullet  be  deformed,  or  strike  the  gut  obliquely,  the  wound  may  be  oval  or 
ragged  and  irregular  in  shape,  and  much  larger  than  the  bullet.  Revolver 
bullets  cut  furrows  or  canals  in  solid  organs,  the  edges  of  which  are  contused, 
sometimes  fissured.  Bullets  which  strike  the  intestine  tangentially  may  cut 
peritoneum,  or  peritoneum  and  muscularis,  without  penetrating  the  mucosa; 
a  shallow  furrow  may  be  created,  or  a  flap  of  the  outer  layers  of  the  gut  may 
be  stripped  up  from  an  area  of  an  inch  or  more.  If  the  tissues  are  not  frayed 
and  contused  such  a  flap  may  be  sutured  in  place  with  safety. 

In  the  stomach  and  intestine  revolver  bullets,  unless  they  strike  obliquely 
or  tangentially,  make  round  perforations  or  oval  holes  somewhat  larger  than 
the  size  of  the  bullet.  The  orifice  of  exit  is  usually  little  if  any  larger  than 
that  of  entrance.  The  edges  of  the  openings  are  more  or  less  contused.  Large, 
soft-lead  rifle  bullets,  express  bullets  (hollow-pointed),  and  soft-nosed  jacketed 
bullets,  from  high-powdered  rifles,  produce  very  extensive  lacerations  of  hollow 
organs,  and  churn  up  solid  organs — liver,  spleen,  and  kidney — into  a  pulp. 
Such  wounds  scarcely  come  under  operative  treatment. 

Wounds  of  the  mesentery  often  accompany  gunshot  wounds  of  the  intes- 
tine, and  are  a  common  cause  of  free  bleeding.  They  should  be  carefully 
sought  for.     If  the  mesentery  is  extensively  wounded  close  to  the  intestinal 


SUBCUTANEOUS   INJURIES   OF   ABDOMINAL   CONTENTS         739 

border,  the  vitality  of  a  portion  of  gut  may  be  imperiled.  The  appearance  of 
the  intestine  is  a  safe  guide  in  deciding  the  question  for  or  againsl  resection. 
(Further  details  of  diagnosis  will  be  found  under  Wounds  of  Organs.) 

Subcutaneous  Injuries  of  Abdominal  Contents. — Subcutaneous  in- 
juries of  the  belly  occur  from  blunt  violence  of  all  kinds — blows,  falls,  kicks, 
the  tread  of  a  horse;  falls  from  a  height  against  a  projecting  object;  falls  from 
a  height  upon  the  feet  or  buttocks;  falls  from  a  height  upon  the  belly  in  water; 
run-over  accidents;  compression  of  the  belly  between  two  hard  objects,  rail- 
way-car buffers,  etc.  The  injuries  to  the  viscera  are  produced  in  various  ways. 
A  direct  blow  over  a  small  area  may  rupture  an  underlying  solid  organ — liver, 
spleen,  kidney;  or  burst  a  hollow  organ,  if  distended — gall-bladder,  stomach, 
intestine,  urinary  bladder.  The  distended  stomach  or  urinary  bladder  may 
either  of  them  be  ruptured  by  moderate  degrees  of  violence.  The  presence 
of  pathological  changes  in  the  stomach,  ulceration  or  scar  tissue,  increases  the 
likelihood  of  rupture.  The  stomach  usually  ruptures  at  or  near  the  lesser 
curvature,  nearer  the  pylorus  than  the  cardia ;  the  rupture  is  commonly  a 
longitudinal  tear.  In  some  cases  direct  compression  of  the  viscera  against  the 
spine  or  pelvis  may  occur — in  run-over  accidents,  compression  by  railway  buf- 
fers, etc.  Thus,  rupture  by  bursting,  tearing,  or  contusion  of  organs  is  pro- 
duced— pancreas,  stomach,  intestine.  A  fractured  rib  may,  by  a  continuance 
of  the  violence,  wound  the  liver  or  kidney.  The  latter  is  very  rare.  I  have 
seen  instances  of  both  these  lesions.  In  falls  from  a  height  the  violent  com- 
motion of  the  entire  body  may  tear  movable  from  fixed  portions  of  the  intes- 
tines— the  jejunum  from  the  duodenum,  the  ileum  from  the  cecum,  or  tear 
the  blood-vessels  of  the  mesentery. 

While,  generally,  the  injuries  following  blows  and  crushes  occur  to  the 
immediately  underlying  organs,  such  is  not  always  the  case ;  a  somewhat  dis- 
tant organ  may  also  be  injured.  In  a  good  many  cases  the  history  of  the  acci- 
dent, the  presence  of  contusions  or  abrasions  of  the  abdominal  wall,  of  frac- 
tured ribs,  of  a  fracture  of  the  pelvis,  will  aid  in  locating  the  seat  of  the 
intra-abdominal  injury.  In  many  cases  the  injuries  are  multiple.  One  of  the 
difficulties  in  the  early  diagnosis  is  that  a  contused  portion  of  intestine  may 
not  slough  and  perforate  for  many  days.  The  same  is  true  of  those  cases  in 
which  the  mesentery  is  torn  away  from  the  gut,  gangrene  and  perforation  of 
the  latter  may  be  long  delayed. 

Groups  of  Symptoms  Observed  in  Subcutaneous  Injuries  of  the  Abdomen. 
— In  general,  the  diagnosis  of  subcutaneous  injuries  of  the  abdominal  contents 
depends  upon  the  history  of  the  injury  and  upon  observation  of  several  sets 
of  local  and  general  signs  and  symptoms.  There  may  be  present:  (1)  Shock; 
(2)  symptoms  of  intraperitoneal  hemorrhage;  (3)  symptoms  due  to  rupture 
of  the  gastro-intestinal  tract;  (4)  symptoms  due  to  rupture  of  other  organs. 
(See  Liver,  Spleen,  etc.) 

As  stated,  severe  contusions  of  the  abdomen  are  quite  commonly  attended 
by  marked  symptoms  of  shock,  already  described;  such  is  not  always  the  case. 


740  THE   PERITONEUM 

I  recall  a  young  man  who  walked  into  the  hospital  with  a  ruptured  kidney 
from  a  fall  upon  the  loin.  He  concluded  to  walk  home  again,  and  was  brought 
back  to  the  hospital  in  a  dying  condition  from  hemorrhage.  The  kidney  was 
extensively  contused  and  ruptured.  Many  similar  observations  have  been  made 
in  cases  of  rupture  of  the  liver,  stomach,  intestine,  and  urinary  bladder.  Should 
the  symptoms  of  shock  be  present  after  the  accident,  persist  for  some  hours,  in 
spite  of  rest  and  suitable  treatment,  and  should  abdominal  pain,  tenderness, 
and  rigidity  increase,  together  with  the  signs  of  progressive  anemia — pallor, 
thirst,  restlessness,  a  thready,  rapid  pulse — intra-abdominal  bleeding  of  a  serious 
character  is  present.      (See  also  Wounds  of  the  Abdominal  Contents.) 

Ruptures  of  the  Alimentary  Tract,  the  Stomach,  or  Intestine. — The  symp- 
toms and  signs  of  rupture  of  the  stomach  or  intestine  in  typical  cases  are  as 
follows:  The  patient  feels  a  sudden  very  severe  pain  at  the  seat  of  rupture. 
The  symptoms  of  shock  appear  at  once,  or  in  a  very  short  time.  If  there  are 
other  severe  associated  injuries  he  may  speedily  become  unconscious  and  die. 
If  not,  he  may  react  after  a  variable  time.  His  pulse  and  appearance  may 
improve.  The  pain  continues  unabated.  There  is  local  rigidity  and  tenderness 
of  the  abdominal  wall.  There  is  often  hiccough.  Nausea  is  felt,  and  is  fol- 
lowed by  vomiting  in  most  cases.  In  some  cases  of  rupture  of  the  stomach 
there  may  be  no  vomiting.  The  contents  of  the  stomach  may  find  a  ready 
avenue  of  escape  into  the  peritoneal  cavity.  In  ruptures  of  the  gut  vomiting 
is  regularly  present ;  the  vomiting  is  repeated  a  number  of  times ;  the  continu- 
ance of  the  vomiting  strongly  suggests  injury  of  the  alimentary  tract.  Follow- 
ing simple  contusions,  one  or  two  acts  of  vomiting  are  common,  but  not  fre- 
quently repeated  vomiting.  The  vomited  matters  consist  of  the  contents  of 
the  stomach;  later,  of  bile-stained  fluid.  Blood  in  the  vomit  suggests  an  injury 
of  the  stomach,  not  necessarily  a  perforation.  A  bloody  stool,  rather  a  lacera- 
tion of  the  mucous  membrane  of  the  bowel  than  a  rupture.  Within  a  few  hours 
there  are  added  the  symptoms  of  peritonitis  (see  Wounds  of  Abdominal  Con- 
tents) ;  the  flat  or  concave  abdomen  gradually  becomes  distended.  The  escape 
of  gas  may  give  rise  to  exaggerated  tympanitic  resonance  around  the  umbilicus 
or  to  diminution  or  absence  of  liver  dullness.  The  evidences  of  free  fluid  in 
the  belly  will  not  be  present  unless  the  quantity  of  escaped  intestinal  contents 
is  very  large ;  there  will  then  be  dullness  in  the  flanks.  It  is  stated  that  such 
dullness  may  be  more  marked  on  that  side  of  the  belly  nearer  to  which  the 
perforation  took  place.  After  a  few  hours  the  whole  picture  gradually  changes 
to  that  of  diffuse  purulent  peritonitis.  In  many  cases  the  symptoms  of  shock 
simply  merge  in  a  few  hours  into  those  of  the  most  intense  peritoneal  sepsis. 
(See  Peritonitis.)  In  those  cases  complicated  by  rupture  of  solid  organs  or  by 
rupture  of  blood-vessels  the  early  symptoms  will  be  rather  those  of  shock  and 
acute  progressive  anemia,  together  with  the  local  signs  and  symptoms  already 
described.  I  think  it  worth  while  to  reiterate  that  shock  may  be  entirely 
absent.  Following  an  injury  to  the  abdomen  the  patient  will  suffer  acute 
abdominal  pain,  and  will  go  on  to  develop  diffuse  purulent  peritonitis,  or  in 


RUPTURE  OF  THE  INTESTINE  741 

some  cases  of  delayed  perforation,  a  localized  peritonitis  and  fecal  abscess.  In 
a  good  many  cases  no  absolutely  certain  diagnosis  of  rupture  of  the  gut  can 
be  made  during  the  early  hours  following  the  injury.  In  others,  although 
reasonably  sure  that  a  rupture  exists,  we  are  unable  to  tell  what  portion  of 
the  intestinal  tract  is  injured.  In  the  treatment  of  these  cases  we  should  remem- 
ber that  if  an  operation  is  to  be  done  at  all,  the  sooner  it  is  done  the  better  the 
chances  of  recovery.  The  surgeon  will  not,  of  course,  open  the  belly  of  an 
actually  moribund  individual.  In  other  cases  less  desperate  he  will  delay  the 
operation,  and  seek  by  warmth  and  other  stimulating  measures  to  get  the 
patient  into  better  condition  and  to  make  a  definite  diagnosis.  Some  of  these 
cases  will  be  saved  even  by  a  delayed  operation.  In  still  other  cases  the  symp- 
toms of  perforation  will  not  appear  for  many  hours,  or,  in  cases  of  delayed 
perforation,  not  for  many  days.  The  symptoms  of  shock  will  pass  away,  and 
the  patient  enjoy  a  longer  or  shorter  period  of  relative  comfort,  to  be  followed, 
suddenly  or  gradually,  by  symptoms  which  vary  according  to  the  following 
local  conditions:  The  rupture  may  be  closed  by  prolapsed  mucous  membrane, 
notably  if  the  organ  is  empty.  Leakage  may  finally  take  place,  to  be  followed 
by  progressive  fibrino-purulent  peritonitis,  or  adhesions  may  form,  closing  off 
the  site  of  the  perforation.  Several  results  are  then  possible;  in  rare  cases 
no  leakage  will  occur,  the  perforation  will  heal.  In  others,  the  adhesions  will 
break  down  with  the  production  of  a  progressive  peritonitis  or  of  a  localized 
peritonitis  with  abscess;  and  these  conditions  will  give  their  characteristic 
signs  and  symptoms;  such  an  abscess  may  break  into  the  intestine,  perforate 
the  diaphragm  into  the  pleura,  or  even  the  abdominal  wall.  (See  Peritonitis.) 
In  the  cases  of  delayed  perforation  from  contusion  of  the  wall  of  the  gut, 
sloughing  may  finally  take  place  and  peritonitis  develop  at  the  end  of  a  week 
or  ten  days.  If  the  original  perforation  be  small  and  the  leakage  slow,  and, 
notably,  if  it  takes  place  in  a  pocket  of  peritoneum,  the  bottom  of  the  pelvis, 
the  lesser  peritoneal  sac,  and  if  the  bacteria  be  not  very  virulent  and  the  amount 
of  intestinal  contents  extruded  small,  there  will  follow  the  original  injury  in 
twelve  to  twenty-four  hours  the  signs  and  symptoms  of  a  localized  peritonitis, 
gradually  or  slowly  developing,  usually  ending  in  the  formation  of  an  abscess. 
Lastly,  as  stated  under  wounds  of  the  viscera,  if  the  rupture  occurs  in  a  part 
of  the  gut  not  covered  by  peritoneum — posterior  surface  of  ascending  colon, 
descending  colon,  or  posterior  surface  of  descending  portion  of  duodenum — a 
localized  abscess  will  form  outside  the  peritoneal  cavity,  or  a  septic  phlegmonous 
inflammation,  with  the  production  of  definite  signs  and  symptoms.  It  has 
been  my  own  practice  in  subcutaneous  injuries  of  the  abdomen,  especially  in 
those  cases  showing  signs  of  progressive  anemia,  to  operate  at  once  in  spite  of 
pretty  severe  symptoms  of  shock;  a  number  of  these  cases  with  rupture  of 
solid  organs — liver,  kidney,  spleen — have  recovered.  Ether  acts  as  a  powerful 
heart  stimulant,  and  under  the  anesthetic  the  symptoms  of  shock  will  often 
diminish  or  disappear;  other  stimulants,  including  saline  infusions,  may  be 
given  on  the  operating  tabic,  the  latter  after  any  source  of  active  bleeding  has 


742  THE  PERITONEUM 

been  controlled.  A  number  of  cases  have  died,  but  not,  in  my  judgment, 
because  of  the  operation.  In  cases  where  the  diagnosis  remains  uncertain 
the  patient  should  be  watched  with  care  and  treated,  as  far  as  rest,  diet,  etc., 
are  concerned,  as  though  a  perforation  existed ;  such  cases  cannot  be  considered 
out  of  danger  for  a  fortnight.  The  use  of  morphin  should  as  far  as  may  be 
omitted.  The  development  of  the  signs  of  peritonitis  are  an  indication  for 
immediate  operation. 


CHAPTER    XXV 

INJURIES  OF  SPECIAL  ABDOMINAL  ORGANS 

The  Stomach. — Aside  from  the  history  of  the  accident,  the  situation  of  the 
contusion  or  wound  and  the  signs  and  symptoms  mentioned  in  the  preceding 
chapter,  it  is  difficult  to  give  any  certain  differential  signs  whereby  we  may 
conclude  that  the  stomach  alone  is  injured.  Often  we  are  obliged  to  content 
ourselves  with  the  diagnosis,  perforation,  or  rupture  of  some  part  of  the  ali- 
mentary tract,  until  the  abdomen  is  explored. 

Injuries  of  the  Duodenum. — The  duodenum  is  rather  rarely  injured  as  the 
result  of  stab  and  gunshot  wounds.  Rather  often  as  the  result  of  blunt 
violence;  since,  being  fixed  and  lying  partly  against  the  spine,  it  cannot  slip 
away  from  a  compressing  force  as  readily  as  the  more  movable  portions  of  the 
intestine.  In  a  number  of  cases  the  rupture  has  been  complete,  the  duodenum 
being  torn  completely  across  at  its  junction  with  the  pylorus.  If  the  rupture 
occurs  in  the  intraperitoneal  portion  of  the  gut,  diffuse  peritonitis  is  the  result. 
If  in  the  retroperitoneal  portion,  a  retroperitoneal  phlegmonous  process  or 
an  abscess  with  or  without  a  secondary  peritonitis.  Intraperitoneal  rupture 
can  scarcely  be  differentiated  from  rupture  of  the  stomach.  The  pain  is  re- 
ferred rather  to  the  right  of  the  middle  line.  Vomiting  of  the  contents  of  the 
stomach  or  of  blood  occur  in  about  half  the  cases.  In  these  cases  which  do 
not  involve  the  peritoneum  there  will  be  a  fixed,  continuous,  deep  pain  in 
the  epigastrium,  localized  tenderness  and  rigidity,  pronounced  septic  symp- 
toms, sometimes  the  formation  of  a  palpable  mass  as  the  abscess  increases 
in  size. 

Injuries  of  the  Jejunum  and  Ileum. — Injuries  of  the  jejunum  and  ileum 
are  frequent  both  as  the  result  of  open  wounds  and  contusions  of  the  abdomen. 
Open  wounds,  especially  gunshot  wounds,  usually  cause  multiple  perforations. 
As  already  indicated,  complete  rupture  may  take  place  as  the  result  of  blunt 
violence,  notably  at  the  flexura  duodeno-jejunalis  and  at  the  ileo-colic  junction. 
I  have  seen  several  complete  ruptures  in  other  situations  from  kicks  and  blows 
upon  the  abdomen.  In  several  cases  the  contusion  of  the  abdomen  was  not  fol- 
lowed by  very  marked  symptoms  at  once.  Sloughing  and  perforation  of  the 
contused  gut  took  place  only  after  several  days.  The  peritonitis  following 
wounds  and  ruptures  of  the  small  intestine  is  of  a  severe  type.     Two  cases 

treated  by  me  in  the  Roosevelt  Hospital  may  serve  as  illustrations: 

743 


744  INJUKIES    OF   SPECIAL   ABDOMINAL   OKGANS 

Case  I. — A  man  of  fifty-five  was  kicked  by  another  in  the  lower  part  of  the 
belly.  He  had  a  severe  pain  in  the  abdomen,  vomited,  and  felt  weak,  but  was  able 
to  walk  home,  where  he  remained  in  bed.  During  the  next  forty-eight  hours  he 
suffered  but  little.  His  general  condition  remained  good.  On  the  third  day  he 
was  suddenly  seized  with  violent  pain  in  the  abdomen,  repeated  vomiting,  and  pros- 
tration. He  remained  at  home  thirty-six  hours  longer,  and  was  brought  to  the 
hospital  in  the  ambulance  on  the  morning  of  the  fifth  day  after  the  injury.  At 
that  time  he  was  severely  ill,  countenance  pinched,  pulse  150  and  thready,  tem- 
perature 102°  F.,  respiration  36,  cerebration  clear.  Abdomen  distended,  tender, 
and  rigid,  everywhere  tympanitic.  The  liver  dullness  absent.  There  was  a  contusion 
of  the  abdominal  wall  to  the  left  of  the  umbilicus.  Immediate  abdominal  incision 
in  the  middle  line  above  and  below  umbilicus,  under  ether  anesthesia.  Upon  open- 
ing the  peritoneum  a  gush  of  foul-smelling  gas,  pus,  and  intestinal  contents  escaped 
under  tension.  There  was  a  rupture  of  the  ileum  near  the  jejunum,  involving  one 
half  the  circumference  of  the  gut.  The  wall  of  the  intestine  was  contused  and  its 
vitality  impaired  over  half  its  circumference  for  a  distance  of  three  quarters  of  an 
inch  on  either  side  of  the  perforation.  Eesection  of  contused  portion  of  gut.  End- 
to-end  anastomosis  by  suture.  Irrigation  of  belly.  Peritoneal  cavity  contained  a 
large  amount  of  pus,  fibrin,  and  intestinal  contents.  There  were  no  limiting  adhe- 
sions; the  process  was  diffuse.  The  intestine,  except  in  the  vicinity  of  the  rupture, 
was  distended  and  evidently  paralyzed.  No  movement  of  the  bowels  had  occurred 
since  the  injury.  Partial  closure  of  abdominal  wound.  Drainage.  Death  the  fol- 
lowing day  without  improvement  of  symptoms. 

Case  II. — A  young  man  was  kicked  in  the  center  of  the  abdomen  by  a  horse. 
He  fell,  vomited,  and  was  brought  to  the  hospital  in  a  state  of  profound  shock. 
He  complained  of  intense  pain  in  the  lower  half  of  the  belly.  The  abdomen  was 
concave,  rigid,  and  tender,  notably  over  the  lower  half.  The  condition  of  the 
patient  was  so  bad  that  rest  and  stimulating  measures  were  used  for  five  hours 
before  his  belly  was  opened.  Median  incision  under  ether.  Abdomen  contained 
a  good  deal  of  intestinal  contents  and  some  gas.  There  was  a  complete  rupture  of 
the  ileum  near  the  cecum,  extending  a  short  distance  into  the  mesentery;  bleed- 
ing had  not  been  active.  Union  of  the  divided  ends  of  ileum,  after  trimming,  with 
the  Murphy  button.  Irrigation  of  abdomen  and  closure  of  wound.  Death  six 
hours  later,  with  continuance  of  symptoms  of  shock.     No  autopsy. 

Case  III. — A  young  man  was  thrown  from  a  bicycle,  striking  his  umbilical 
region  against  a  post.  Severe  pain  and  abdominal  rigidity  with  marked  shock. 
Operation  the  following  day.  Three  ruptures  of  small  intestine,  jejunum,  and 
ileum;  one  of  them  a  complete  severance  of  the  gut.  Diffuse  purulent  peritonitis. 
Exitus  letalis  in  forty-eight  hours. 

Wounds  and  Ruptures  of  the  Mesentery. — Wounds  and  ruptures  of  the  mes- 
entery frequently  complicate  injuries  of  the  small  gut.  The  signs  and  symp- 
toms of  injuries  of  the  mesentery  alone  are  those  of  intra-abdominal  bleeding. 
The  following  case  history  illustrates  the  symptoms  and  course  of  a  gunshot 
wound  of  the  stomach  and  small  intestine  and  mesentery: 


WOUNDS  AND  RUPTURES  OF  THE  MESENTERY      745 

Bullet  Wound  of  the  Stomach  and  Small  Intestine. — A  man,  aged  thirty- 
five  years,  was  admitted  to  Roosevelt  Hospital  on  the  afternoon  of  April  2, 
1899,  at  5.40  p.m.,  with  the  history  that  one  hour  before  he  had  been  ap- 
proached by  another  man  who  pushed  a  .38  caliber  revolver  against  the  front 
of  his  abdomen  and  fired  the  contents  of  the  weapon  through  his  body. 

The  wounded  man  preserved  sufficient  strength  to  get  into  a  cab,  which 
happened  to  be  near,  and  was  driven  at  once  to  Roosevelt  Hospital.  Upon 
admission  the  patient  was  seen  to  be  a  man  in  robust  health,  and  evidently 
in  the  most  perfect  physical  condition.  He  was  fully  clad,  and  wore  an  over- 
coat, through  the  front  of  which  over  the  abdomen  was  a  hole  burned  an  inch 
or  more  in  diameter,  with  corresponding  perforations  in  his  coat,  waistcoat, 
shirt,  and  undershirt.  When  undressed  and  placed  in  bed,  a  .38  caliber,  con- 
ical, lead  bullet  dropped  out  of  his  clothing.  Considerable  hemorrhage  had 
occurred  from  a  wound  of  exit  in  his  back.  He  appeared  to  be  suffering  from 
shock  and  hemorrhage;  he  was  pale.  His  temperature  was  subnormal,  97.2° 
F. ;  pulse,  88,  soft  and  compressible ;  respirations,   22. 

He  complained  of  intense  distress  in  the  abdomen  and  begged  for  relief. 
Examination  of  the  abdominal  wall  in  front  showed  a  powder  burn  and  a 
ragged  perforation  in  the  skin  at  its  center,  situated  three  inches  below  the 
ensiform  cartilage  and  an  inch  to  the  right  of  the  median  line.  The  powder 
burn  was  quite  superficial  and  about  an  inch  in  diameter;  this  wound  did 
not  bleed. 

Upon  examining  the  patient's  back  the  wound  of  exit  was  seen  to  the  left 
of  the  median  line,  and  four  inches  from  it,  just  above  the  posterior  superior 
iliac  spine. 

The  wound  of  exit  was  small,  and  when  examined  had  ceased  to  bleed. 
At  6.25  p.m.,  about  an  hour  and  forty-five  minutes  after  the  receipt  of  the 
injury,  under  ether,  an  incision  was  made  in  the  median  line  of  the  abdo- 
men, from  a  point  two  inches  below  the  ensiform  cartilage,  downward  to  an  inch 
and  a  half  below  the  navel.  Upon  opening  the  abdominal  cavity  a  large  amount 
of  fluid  blood  escaped.  The  stomach  presented  in  the  wound.  A  perforation 
was  found  in  its  anterior  wall  near  the  lesser  curvature  and  about  two  inches 
removed  from  the  pylorus.  An  artery  of  some  size  at  the  edge  of  this  perfora- 
tion was  bleeding  freely,  and  was  ligated.  The  muscular  coat  was  denuded 
of  peritoneum  around  the  borders  of  this  hole,  forming  a  solution  of  continuity 
in  the  latter  membrane  of  the  diameter  of  an  inch.  The  mucous  membrane 
showed  a  ragged  everted  border,  and  from  the  cavity  of  the  stomach  bile- 
stained  stomach  contents  and  gas  were  freely  escaping.  This  perforation  was 
closed  by  two  purse-string  sutures,  one  outside  the  other,  and  the  closure 
reenforced  by  five  mattress  stitches,  all  of  catgut.  The  gastrocolic  omentum 
was  then  torn  through,  the  hand  inserted  into  the  lesser  peritoneal  cavity,  the 
stomach  dragged  out  through  the  rent,  and  its  posterior  surface  examined. 

A  perforation  similar  in  character  to  that  upon  the  anterior  surface  was 
found  about  an  inch  and  a  half  front  the  greater  curvature,  and  much  farther 


746  INJURIES    OF    SPECIAL   ABDOMINAL   OKGANS 

to  the  left  than  the  anterior  perforation.  From  it  also  stomach  contents  were 
escaping.  It  was  closed  by  suture  in  the  same  manner  as  the  anterior  perfora- 
tion, but  with  rather  more  difficulty.  The  rent  in  the  gastrocolic  omentum 
was  held  widely  open,  and  the  lesser  peritoneal  cavity  repeatedly  flushed  out 
with  hot  sterile  salt  solution;  afterwards  it  was  wiped  dry  with  large  pads  of 
sterile  gauze.  Search  was  then  made  for  intestinal  perforation ;  it  soon  became 
evident  that  the  question  of  hemorrhage  required  immediate  attention,  the 
manipulations  having  evidently  caused  an  increased  amount  of  bleeding  of  the 
most  serious  character. 

At  this  time  the  patient's  color,  breathing,  and  pulse  underwent  a  sudden 
change  for  the  worse,  and  blood  welled  up  from  among  the  coils  of  intestines 
in  a  manner  which  rendered  a  decision  as  to  its  source  somewhat  difficult. 
After  a  few  moment's  search  a  jagged  tear  was  found  in  the  mesentery  of  the 
first  coil  of  the  jejunum,  about  five  inches  below  the  insertion  of  Treitz's 
ligament,  and  close  to  the  border  of  the  gut.  Several  vessels  in  the  borders 
of  this  wound  of  the  mesentery  were  bleeding  rapidly.  The  contused  edges  of 
this  wound  rendered  the  use  of  ordinary  hemostatic  forceps  difficult,  and  the 
edges  of  the  tear  were  therefore  surrounded  or  included  in  three  catgut  liga- 
tures passed  by  means  of  an  aneurism  needle. 

Opposite  to  this  wound  of  the  mesentery  the  jejunum  was  perforated,  and 
from  the  hole  intestinal  contents  were  escaping.  The  long  axis  of  the  per- 
foration lay  transversely  to  the  caliber  of  the  gut. 

The  wound  was  closed  by  a  row  of  Lembert  stitches  inserted  in  a  line  at 
right  angles  to  the  axis  of  the  intestine.  An  inch  and  a  half  from  this  per- 
foration the  intestine  had  been  scored  by  the  bullet  for  a  distance  of  two  inches 
and  a  half,  in  such  a  manner  as  to  split  the  peritoneal  covering  of  the  gut, 
laying  bare  the  muscular  coat  over  a  considerable  area.  The  edges  of  the  torn 
peritoneum  were  stitched  together,  thus  closing  the  rent.  Fine  catgut  was 
used  on  all  the  sutures. 

The  injury  to  the  mesentery  lying  close  to  the  intestine  and  immediately 
opposite  to  the  site  of  the  intestinal  perforation  would,  in  the  then  opinion 
of  the  writer,  have  demanded  a  resection  of  that  portion  of  the  bowel,  but, 
in  spite  of  stimulation  of  the  most  active  kind,  the  patient's  condition  at  this 
time  forbade  any  further  operative  measures.  He  was  pulseless  with  dilated 
pupils,  the  tension  of  the  eyeballs  reduced,  and  the  breathing  shallow,  infre- 
quent, and  gasping. 

"W  hile  the  latter  part  of  the  operation  was  going  on  preparations  were 
made  for  intravenous  infusion  of  salt  solution.  It  required  some  persuasion 
on  my  part  to  induce  the  house  surgeon  to  make  this  infusion,  because,  he 
said,  the  man  did  not  bleed;  his  veins  were  empty;  he  had  no  pulse;  he  had 
ceased  to  breathe,  and  was  therefore  dead.  The  infusion  was  commenced, 
and  after  some  4  00  or  500  c.c.  of  hot  water  and  salt  had  been  added  to  the 
patient's  circulation,  signs  of  returning  vitality  were  evident.  The  infusion 
was  continued  until  1,800  c.c.  had  been  given  al  a  temperature  of  118°  F, 


WOUNDS  AND  RUPTURES  OF  THE  MESENTERY      747 

When  the  infusion  was  finished  the  patient  was  breathing  regularly,  he 
had  a  pulse  of  120,  and  of  fair  quality,  and  his  color  was  much  improved. 
While  the  infusion  was  being  administered  the  abdominal  cavity  was  repeat- 
edly flushed  with  hot  sterile  salt  solution,  all  fluid  blood  and  clots  were  re- 
moved, and  the  cavity  wiped  dry  with  sterile  pads.  A  strand  of  gauze  was 
carried  down  to  the  site  of  perforation  in  the  jejunum,  and  brought  out  of 
the  upper  angle  of  the  wound. 

While  flushing  the  abdomen  a  wide  rent  was  found  in  the  inner  edge 
of  the  descending  mesocolon,  through  which  three  fingers  could  be  introduced 
through  the  muscles  of  the  back  to  the  wound  of  exit  in  the  skin.  (This  wound 
did  not  bleed,  and  was  merely  washed  out  and  wiped  dry  with  gauze.)  The 
wound  in  the  transverse  mesocolon,  through  which  the  bullet  passed  after  leav- 
ing the  stomach  and  before  entering  the  jejunum,  did  not  bleed,  and  there- 
fore its  exact  position  was  not  noted.  The  wound  was  closed  by  layers  with 
buried  catgut  and  superficial  silk  stitches.  The  time  from  the  beginning  of 
the  anesthesia  until  the  patient  was  removed  from  the  operating  table  was  an 
hour  and  ten  minutes.  Following  the  operation  the  patient  was  stimulated 
with  strychnin  and  digitalin,  one  thirtieth  and  one  fiftieth  of  a  grain  re- 
spectively, every  two  hours.  He  received  enemata  of  coffee  and  whisky,  and 
to  relieve  thirst,  and  to  replace  as  far  as  possible  the  loss  of  fluids,  he  was 
given  enemata  of  normal  salt  solution,  a  quart  at  a  time,  every  six  hours. 
For  the  first  four  days  he  received  nothing  by  mouth  but  small  doses  of  hot 
water. 

On  the  day  following  the  operation  his  temperature  rose  to  101.4°  F.  By 
the  end  of  the  second  day  his  pulse  had  fallen  to  80,  and  was  of  good  quality. 

Soon  after  the  operation  the  patient  began  to  suffer  from  severe  and  con- 
tinuous hiccoughs,  which  could  only  be  controlled  for  a  few  hours  at  a  time 
by  full  doses  of  morphin ;  he  vomited  at  intervals  during  the  first  five  days 
considerable  quantities  of  dark  chocolate-colored  fluid.  This  vomiting  was 
treated  upon  the  fourth  day  and  thereafter  by  frequent  washing  out  of  the 
stomach  with  warm  water,  which  rendered  the  vomiting  less  distressing  and 
diminished  the  severity  of  the  hiccoughs.  Upon  the  fourth  day  the  gauze 
drainage  was  removed  from  the  abdomen  and  appeared  clean.  The  external 
wound  remained  aseptic. 

Upon  the  fifth  day  the  amount  of  vomiting  appeared  to  be  increasing; 
the  patient  was  suffering  from  severe  abdominal  pain  and  hiccoughs ;  his  tem- 
perature had  risen  from  normal  to  100.6°  F. ;  his  pulse  had  become  rapid  and 
more  feeble.  Owing  to  these  symptoms,  which  seemed  to  show  that  there  was 
a  constant  regurgitation  of  intestinal  contents  into  the  stomach,  and  owing  to 
the  supposed  feeble  nutrition  of  the  gut  at  the  site  of  the  perforation  in  the 
jejunum,  on  account  of  its  diminished  blood  supply,  it  was  feared  that  the 
intestine  might  have  undergone  necrosis  at  this  point,  and  for  these  reasons 
the  patient  was  again  etherized  upon  the  evening  of  the  fifth  day,  the  upper 
part  of  the  abdominal  wound  was  opened,  and  the  jejunum  and  mesentery  at 


748  INJURIES    OF    SPECIAL   ABDOMINAL   ORGANS 

the  point  of  injury  were  carefully  inspected.  No  adhesions  except  of  the 
slightest  character  were  found.  The  belly  was  dry,  the  uppermost  coils  of  small 
intestine  appeared  flabby,  slightly  reddened,  but  not  distended. 

The  site  of  the  wound  of  the  mesentery  could  only  be  distinguished  as  a 
moderately  reddened  depression,  close  to  the  border  of  the  gut.  At  the  point 
of  perforation  in  the  gut  itself  could  be  seen  merely  a  very  slight  reddened 
projection,  to  which  a  minute  portion  of  catgut  adhered.  The  stomach  was 
not  inspected.      The  wound  was  closed  with  sutures. 

LTpon  the  day  following  this  operation  the  patient's  temperature  rose  to 
102.4°  F.  He  continued  to  vomit  and  to  hiccough.  After  washing  of  the 
stomach  he  was  fed  with  beef  juice  by  the  mouth.  In  the  afternoon  of  that  day 
he  was  given  calomel  in  divided  doses,  which  was  effective  on  the  day  follow- 
ing, after  which  his  general  condition  was  greatly  improved. 

His  temperature  and  pulse  soon  fell  to  normal;  he  ceased  to  vomit;  the 
hiccoughs  persisted,  but  grew  less  intense  and  with  remissions.  Although  the 
wound  in  the  abdominal  wall  remained  entirely  aseptic,  yet  the  superficial 
portion  of  the  wound  at  its  upper  part  failed  to  unite  completely  by  primary 
union  after  it  had  been  resutured,  necessitating  the  use  of  straps  and  stimulating 
applications.  The  patient  was  allowed  to  get  up  out  of  bed  upon  the  nineteenth 
day,  since  when  his  convalescence  had  been  rapid,  except  for  occasional  attacks 
of  indigestion,  brought  about  by  the  incautious  use  of  food.  He  rapidly  re- 
gained his  physical  strength,  and  thirty-eight  days  after  the  injury  he  was 
able  to  eat  heartily  and  to  walk  several  miles  without  undue  fatigue. 

An  unusual  and  interesting  observation  was  made  some  years  ago  by 
Dr.  Charles  McBurney  in  the  Roosevelt  Hospital.  A  negro  woman  was  shot 
in  the  epigastrium  with  a  .32  caliber  pistol.  The  bullet  entered  in  the  middle 
line  two  inches  below  the  ensiform  cartilage.  There  was  vomiting  of  blood,  but 
no  symptoms  of  shock.  Upon  opening  the  belly  a  hole  was  found  in  what 
appeared  to  be  the  anterior  wall  of  the  stomach,  since  blood  and  stomach  con- 
tents escaped.  The  peritoneal  cavity  seemed  to  be  obliterated  by  an  old  chronic 
peritonitis  with  adhesions.  The  stomach  could  not  be  freed  from  surrounding 
structures  without  undue  violence.  The  wound  in  the  stomach  was  closed  with 
sutures,  as  Avell  as  the  external  wound  in  part.  The  patient  made  a  rapid 
recovery  without  further  serious  symptoms. 

Wounds  and  Ruptures  of  the  Large  Intestine. — Wounds  and  ruptures  of  the 
large  intestine  differ  but  slightly  in  their  nature,  causation,  and  results  from 
those  of  the  smaller  gut.  The  bacteria  of  the  colon  are  abundant  and  virulent. 
The  contents  of  this  portion  of  the  gut  are  often  solid,  its  peristaltic  motions 
are  slower  and  less  active.  Thus,  sometimes,  leakage  is  slow  or  delayed.  A 
portion  of  the  colon  is  extraperitoneal,  and,  though  relatively  infrequent, 
wounds  and  ruptures  may  result  in  an  extraperitoneal  extravasation  and  the 
production  of  an  abscess  containing  fecal  matter  and  gas,  or  a  septic  and 
necrotic  infiltration  of  the  tissues  of  the  loin.  Such  extravasation  may  be 
quite  slow,  and  the  local  signs  and  symptoms  may  not  appear  for  several  days. 


INJURIES    OF   THE    STOMACH   FROM   WITniN  749 

The  two  following  cases  illustrate  an  intraperitoneal  and  extraperitoneal  injury 
of  the  colon  respectively: 

Case  I. — A  woman  was  stabbed  with  a  dagger  in  the  abdomen  and  brought 
immediately  to  the  New  York  Hospital  and  entered  my  service.  A  linear  wound 
three  fourths  of  an  inch  long  was  found  in  the  left  side  of  the  abdomen,  one  inch 
below  the  costal  border  in  the  anterior  axillary  line.  There  was  no  shock.  Ab- 
dominal pain  was  complained  of  in  the  region  of  the  wound.  Temperature  and 
pulse  normal.  Operation  three  hours  after  the  injury.  Wound  enlarged  and  found 
to  penetrate  the  belly.  Incision  parallel  to  the  ribs.  There  were  three  incised 
wounds  of  the  splenic  flexure  of  the  colon,  each  about  one  third  to  one  half  inch 
in  length.  The  orifices  were  found  plugged  by  prolapsed  mucous  membrane.  No 
leakage  had  occurred.  Suture  with  fine  catgut;  abdominal  wound  closed.  Recovery 
uneventful. 

Case  II.- — In  1886  a  woman  was  shot  from  behind  with  a  .38  caliber  pistol  in 
the  right  loin,  and  brought  to  Bellevue  Hospital.  Shock  was  moderate.  There 
was  a  wound  midway  between  the  last  rib  and  the  crest  of  the  ileum  in  line  with 
the  angle  of  the  scapula.  The  wound  was  round,  5  mm.  in  diameter,  the  edges 
contused.  Bleeding  was  slight.  There  was  no  wound  of  exit.  The  symptoms  of 
shock  passed  away  during  the  first  day.  No  symptoms  of  peritoneal  infection 
occurred.  There  was  no  vomiting.  At  the  end  of  forty-eight  hours  the  patient 
complained  of  pain  in  the  loin,  and  developed  an  irregular  febrile  movement.  The 
external  wound  was  covered  with  a  dry  scab.  On  the  fourth  day  a  tender,  painful 
mass  of  infiltration  could  be  felt  deep  in  the  loin  beneath  the  wound.  The  patient 
felt  ill.  Incision  evacuated  pus,  gas,  and  fecal  matter.  The  wound  was  drained 
with  a  large  tube.  The  patient's  condition  was  improved  by  the  operation.  Pain 
and  fever  subsided.  Fecal  matter  continued  to  be  discharged  from  the  wound.  At 
no  time  was  blood  observed  in  the  stools.  On  the  seventh  day  the  patient  began  to 
show  signs  and  symptoms  of  gradually  increasing  sepsis.  The  wound  in  the  loin 
was  enlarged.  An  extensive  putrid,  necrotic,  and  purulent  inflammation  was  found 
in  the  intermuscular  planes  and  retroperitoneal  loose  connective  tissue.  There  was 
a  ragged  hole  in  the  posterior  wall  of  the  ascending  colon  an  inch  in  diameter. 
The  patient  succumbed  to  septic  poisoning  on  the  fourteenth  day  after  the  shoot- 
ing.    No  autopsy. 

Wounds  of  the  Omentum. — Wounds  and  tears  of  the  omentum  rarely  give 
rise  to  serious  symptoms  if  uncomplicated;  exceptions  occur  (see  case  related). 
As  stated,  the  great  omentum  frequently  protrudes  even  through  very  small 
wounds  of  the  abdominal  wall ;  its  appearance  is  a  positive  and  valuable  sign 
of  penetration. 

Injuries  of  the  Stomach  from  Within. — The  stomach  may  be  injured  by 
swallowing  caustic  fluids,  acids,  and  alkalies — nitric  acid,  sulphuric,  hydro- 
chloric, oxalic,  and  carbolic  acids.  Potassium,  sodium,  and  ammonium 
hydrates;  other  substances,  notably  corrosive  sublimate  and  arsenious  acid,  may 
cause  a  very  intense  inflammation  of  the  stomach.  When  true  caustics  are 
swallowed,  the  mouth,  pharynx,  and  esophagus  are  nearly  always  cauterized. 


750  IX JURIES    OF    SPECIAL   ABDOMIXAL   ORGAXS 

The  lesser  curvature  and  the  pylorus  are  the  parts  of  the  stomach  affected. 
The  intensity  of  the  effect  depends  largely  upon  the  concentration  of  the  caustic 
liquid,  and  varies  from  the  production  of  hyperemia,  catarrhal  inflammation, 
destruction  of  the  mucous  membrane,  to  perforation  of  the  stomach.  The  effects 
of  caustics  upon  mucous  membranes  have  been  described  under  Burns.  Here 
it  may  be  said  of  such  injuries  of  the  stomach: 

The  eschars  produced  by  sulphuric  acid  are  black. 

The  so-called  sulphate  of  indigo,  a  solution  of  indigo  and  sulphuric  acid,  pro- 
duces like  effects.    The  tissues  are  stained  dark  blue.    Perforation  is  not  uncommon. 

Xitric  acid  produces  vellow  eschars.     Perforation  is  rare. 

Hydrochloric  acid  produces  eschars,  at  first  white,  later  discolored.  A  false 
membrane  forms  over  the  cauterized  areas.     Perforation  is  rare. 

Oxalic  acid :  The  mucous  membrane  of  the  stomach  may  be  softened  and 
shredd}r,  looking  as  though  boiled  in  water.  In  other  cases  swollen,  congested,  or 
gangrenous.     Perforation  is  rare. 

Caustic  alkalies,  sodium  and  potassium  hydrate:  The  mucous  membrane  of  the 
stomach  is  softened,  swollen,  congested,  and  inflamed,  or  may  be  tough  and  leather}r, 
or  peeled  off,  or  blackened. 

Corrosive  sublimate  produces  an  intense  inflammation  of  the  mucous  membrane 
of  the  stomach.  Grayish-white  areas  of  false  membrane  may  be  formed;  ecchymotic 
and  gangrenous  areas  m&j  be  present.     Perforation  is  very  rare. 

Arsenious  acid  and  its  compounds  may  cause  diffuse  or  localized  inflammation 
of  the  stomach.  There  may  be  patches  of  false  membrane  containing  particles  of 
the  poison;  ecchynioses  are  common.  Gangrene  and  perforation  are  rare.  Acute 
inflammation  of  the  entire  gastro-intestinal  tract  is  one  of  the  specific  effects  of 
arsenic,  irrespective  of  the  method  of  administration. 

Carbolic  acid  produces  white  sloughs;  later  these  may  turn  black  or  brown;  the 
odor  is  usually  characteristic.     (Delafield  and  Prudden.) 

The  symptoms  produced  by  swallowing  caustics  are,  in  addition  to  those 
referable  to  the  mouth,  pharynx,  and  gullet,  a  violent  pain  in  the  upper  part 
of  the  abdomen,  vomiting  of  the  contents  of  the  stomach.  The  character  of  the 
vomited  material  may  indicate  the  nature  of  the  caustic;  in  severe  cases  vom- 
iting of  blood  or  of  fragments  of  sloughs.  A  good  many  of  the  cases  exhibit 
the  symptoms  of  profound  shock,  from  which  they  do  not  recover.  Others 
die  of  the  specific  effects  of  the  poison ;  still  others  from  phlegmonous  inflam- 
mation of  the  wall  of  the  stomach ;  others  from  perforation  and  the  symp- 
toms of  diffuse  peritonitis.  The  condition  is  interesting  from  a  surgical  point 
of  view,  chiefly  because  among  those  who  survive,  cicatricial  contraction  may 
produce  strictures  of  the  gullet  and  of  the  pylorus;  sometimes  hour-glass  de- 
formity of  the  stomach,  or  chronic  ulcers  develop  at  a  later  period,  and  give 
rise  to  obstructive  and  other  symptoms. 

Foreign  Bodies  in  the  Stomach. — Foreign  bodies  gain  entrance  to  the  stom- 
ach for  the  most  part  through  the  mouth.  Foreign  bodies  are  swallowed  by 
design  by  lunatics,  hysterical  individuals,  criminals,  professional  jugglers,  and 


FOREIGN   BODIES    IN   THE    STOMACH  751 

sword  swallowers;  sometimes  by  children.     They  arc  swallowed   by  accidenl 
with  food,  and  by  children  and  others  who  have  the  dangerous  habit  of  carry- 
ing foreign  bodies  in  their  months.      (See   Injuries  of  and    Foreign    Bodies  in 
the  Esophagus.)     The  variety  of  foreign  bodies  which  may  reach  the  stomach 
is  large;  among  them  may  be  mentioned  needles,  pins,  coins,  buttons,  knives, 
forks,  spoons,  pieces  of  meat  bone,  fish  bones,  beads,  sharp  pieces  of  glass  and 
metal  nails,  screws,  false  teeth  and  tooth  plates,  natural  teeth  and  fragments 
of  teeth,   hairpins,    stones,   wooden    articles    of  various   kinds,    watches,    pipe- 
stems  and  mouthpieces,  of  clay,  rubber,  or  amber,  sword  blades,  portions  of 
stomach  tubes  or  esophageal  bougies.     Rarely  among  human  beings,  very  com- 
monly among  plant-eating  animals,  hair  and  vegetable  fibers  swallowed,  remain 
in  the  stomach  and,  becoming  matted  together,  form   a  ball  of  considerable 
size,  to  which  gradually  additions  are  made  as  more  hair  or  vegetable  fiber  is 
swallowed,  until  a  large  mass  is  formed,  giving  the  signs  and  symptoms  of 
tumor  of  the  stomach.     A  few  such  cases  are  observed  from  time  to  time  among 
human  beings  as  the  result  of  a  habit  of  chewing  and  swallowing  hair,  for  the 
most  part  among  young  girls  whose  hair  is  arranged  in  a  queue,  the  end  of 
which  is  chewed,  or  among  hysterical  women  who  swallow  hair.     The  masses 
composed  of  vegetable  fiber  have  arisen  from  a  diet  containing  large  amounts 
of  coarse  vegetable  fiber.      Foreign  bodies  occasionally  reach  the  stomach  in 
other  ways.      Through  the  abdominal  wall,  as  the  result  of  stab  or  gunshot 
wounds,  a  portion  of  a  knife  blade  or  a  bullet  may  remain  in  the  stomach ;  long 
needles  and  similar  articles  may  do  the  same.     Gall-stones  have  been  found 
in   the  stomach,   having   ulcerated   through   the   gall-bladder   and   pylorus,    or 
reached  the  stomach  from  the  duodenum  by  ulceration.     A  Murphy  button 
sometimes  passes  into  the  stomach  after  the  operation  of  gastroenterostomy. 
Lumbricoid  worms  sometimes  crawl  into  the  stomach  from  the  small  gut.     The 
size  of  foreign  bodies  which  may  pass  the  gullet  and  reach  the  stomach  is  re- 
markable not  only  in  the  case  of  professional  swallowers,but  also  among  ordinary 
individuals.     Sets  of  false  teeth,  large  pieces  of  metal,  large  coins,  knives,  forks, 
spoons,  and  other  large  objects  accidentally  swallowed  often  reach  the  stomach 
without  difficulty.     The  symptoms  produced  by  foreign  bodies  in  the  stomach 
are  varied.     If  the  body  is  small  or  smooth  or  without  sharp  angles,  it  may 
remain   in  the   stomach   indefinitely   and    produce   no    symptoms.      If   sharp- 
pointed,  pointed  at  both  ends,  jagged,  angular,  or  hooked,  it  may  produce  func- 
tional disturbances  or  pressure  ulceration,   or  finally  perforation  and   perito- 
nitis ;  either  diffuse  peritonitis  or  a  localized  abscess.     Such  an  abscess  may 
break  into  some  other  part  of  the  intestinal  tract,  or  outwardly  through  the 
abdominal  wall,  leaving  a  fistula  behind  or  closing  on  removal  of  the  foreign 
body.     Small  sharp  bodies,  like  needles  and  pins,  may  perforate  suddenly  with 
serious  results  or  leave  the  stomach  and  appear  beneath  the  skin  of  the  abdom- 
inal wall  without  evidences  of  inflammation.      (See  case   quoted   in  another 
chapter  of  a  lunatic  who  swallowed  many  needles.)      A  number  of   similar 
cases  are  on  record.      The  functional   disturbances  may  be  loss  of  appetite, 


'52 


IX JURIES    OE    SPECIAL   ABDOMIXAL   ORGAXS 


colicky  pain,  distress  after  eating,  a  sense  of  heaviness,  nausea,  etc.  The  symp- 
toms of  ulceration,  perigastritis,  abscess,  peritonitis,  etc.,  are  described  under 
Peritonitis.  If  the  foreign  body  becomes  impacted  in  the  pylorus,  it  may  pro- 
duce the  symptoms  of  obstruction.  The  records  of  operations  and  autopsies  on 
the  bodies  of  professional  swallowers  show  that  an  extraordinary  number  and 
weight  of  foreign  bodies  of  the  most  varied  size,  shape,  and  character  may 
remain  in  the  stomach  without  producing  serious  symptoms.  (See  Gastric 
Tetany.)  In  most  instances  when  the  body  is  not  too  large,  and  is  not  jagged, 
angular,  hooked,  or  sharp  at  both  ends,  or  is  not  very  sharp  (fragments  of  glass, 
for  example),  it  will  leave  the  stomach,  and  finally  be  passed  per  rectum.  If 
it  possesses  the  undesirable  qualities  mentioned,  it  may  remain  in  the  stomach, 
there  to  cause  trouble  or  pass  the  pylorus  and  cause  perforation,  etc.,  of  some 
portion  of  the  gut.  The  time  during  which  a  foreign  body  may  remain  in  the 
stomach  before  it  passes  the  pylorus,  and  is  finally  evacuated  per  rectum,  varies 
from  a  few  days  to  many  months.  Sometimes  foreign  bodies  in  the  stomach 
are  vomited  after  a  long  interval.  While  waiting  for  a  foreign  body  to  leave 
the  stomach,  the  diet  should  be  starchy;  neither  purgatives  nor  opiates  should 
be  given.  When  the  foreign  body  remaining  in  the  stomach  is  of  considerable 
size  and  weight,  it  may  be  removed  by  gastrotomy  without  serious  risk.  Re- 
cently I  removed  a  fifty-cent  silver  piece  from  the  stomach  of  a  boy  aged  ten. 
Repeated  X-ray  examinations  showed  that  the  coin  remained  in  the  cardiac 

end  of  the  stomach.  Upon 
opening  the  stomach  it  was 
easily  removed  with  the 
forefinger  (see  illustration, 
Fig.  257).  The  diagnosis 
of  foreign  bodies  in  the 
stomach  is  often  highly  im- 
portant ;  at  times  easy,  at 
times  difficult.  The  history 
may  be  plain  or  doubtful, 
the  body  may  have  reached 
the  stomach  after  unsuc- 
cessful efforts  to  extract  it 
from  the  esophagus.  From 
children,  hysterical  people, 
and  fools  it  may  be  impos- 
sible to  obtain  a  reliable 
history.  Hypochondriacal 
lunatics  sometimes  believe  that  they  have  swallowed  foreign  bodies,  usually 
small  animals,  who  continue  to  inhabit  their  stomachs.  These  delusions 
may  have  as  a  basis  gastric  dyspepsia,  etc.  I  saw  an  elderly  lady  who  stated 
that  a  lizard  inhabited  her  stomach,  and  that  at  the  word  of  command  it  would 
crawl  up  on  the  back  of  her  tongue  and  remove  a  piece  of  orange  peel.    Patients 


Fig.  257.  —  Fifty-cent  Silver  Piece  in  the  Cardiac  Por- 
tion of  the  Stomach  Removed  by  Gastrostomy.  (Au- 
thor's collection.) 


FOREIGN   BODIES    IN   THE   INTESTINE  753 

who  have  swallowed  a  foreign  body  often  become  depressed  and  neurasthenic. 
If  the  foreign  body  is  known  to  have  passed  into  the  stomach,  it  may  in  some 
cases  be  seen  in  the  stomach  through  the  esophagoscope  (von  Mikulicz).  If  it 
be  metallic  or  of  such  material  as  to  cast  an  X-ray  shadow,  it  may  be  located 
accurately  by  a  radiograph,  and  its  subsequent  progress  through  the  alimentary 
tract  watched.  The  stools  should  regularly  be  inspected.  If  the  foreign  body 
remains  in  the  stomach  and  produces  inflammation,  ulceration,  or  perforation, 
it  will  produce  definite  symptoms  of  gastric  ulcer,  or  of  localized  or  diffuse 
peritonitis.  If  it  becomes  attached  to  or  wedged  against  the  anterior  wall  of 
the  stomach,  and  is  of  considerable  size,  it  may  be  palpable  through  the  abdom- 
inal wall.  The  diagnosis  of  hair  and  vegetable-fiber  accumulations  in  the 
stomach  has  rarely  been  made  before  operation.  The  symptoms  may  be  pain, 
functional  disturbances  of  the  stomach,  or  none.  The  physical  signs  on  palpa- 
tion are  those  of  a  movable  tumor  of  the  stomach,  which  disappears  upon  the 
patient  assuming  certain  positions.  The  mass  may  be  rounded,  or  if  large 
may  represent  in  shape  a  cast  of  the  stomach.  Such  masses  have  usually  been 
mistaken  for  a  movable  kidney,  a  spleen,  or  a  tumor  of  the  stomach. 

Foreign  Bodies  in  the  Intestine  Below  the  Stomach. — Those  foreign  bodies 
which  succeed  in  passing  the  pylorus  usually  traverse  the  remainder  of  the 
alimentary  canal  without  difficulty.  There  are,  however,  exceptions  to  this 
rule,  to  be  noted  below.  Gall-stones  may  enter  the  intestine  by  ulceration 
from  the  gall-bladder,  and  if  very  large  may  cause  obstructive  symptoms.  Such 
stones  may  by  irritation  produce  a  local  spasm  of  the  muscular  wall  of  the  gut, 
so  that  the  stone  is  tightly  grasped  by  the  intestine,  and  thus  produces  intes- 
tinal obstruction,  although  the  caliber  of  the  canal  may  be  abundantly  large 
to  permit  its  passage.  Instruments,  drainage-tubes,  and  packings  left  in  the 
abdomen  after  surgical  operations  may  ulcerate  into  the  gut.  It  is  also  possi- 
ble that  needles,  pins,  bullets,  knife  blades,  etc.,  introduced  into  the  abdomen 
from  without  should  enter  the  gut  in  the  same  way.  Foreign  bodies  may  also 
originate  in  the  intestine  itself.  Intestinal  concretions  frequently  form  in  the 
large  intestine,  very  frequently  in  the  vermiform  appendix ;  very  rarely  in  the 
small  gut.  Such  concretions  may  be  true  enteroliths,  consisting  of  earthy  salts, 
or  hardened  masses  of  fecal  matter  embedded  in  mucus.  These  concretions 
rarely  reach  a  large  size.  Aggregations  of  vegetable  fibers  and  of  fruit  seeds 
occasionally  form  in  the  large  intestine.  In  rare  cases,  tangled  masses  of 
worms,  Ascaris  lumbricoides  (roundworms),  as  well  as  Oxyuris  vermicularis 
(pinworms),  in  the  intestines  of  children  may  give  rise  to  obstructive  symptoms. 
I  knew  of  a  case  in  which  a  balled-up  mass  of  pinworms  became  impacted  in 
the  ileo-cecal  valve  of  a  child,  caused  acute  intestinal  obstruction,  and  was 
removed  by  operation.  Large  masses  of  fecal  matter  may  collect  in  the  large 
gut  of  people  of  constipated  habits,  old  people,  paralytics,  and  those  who  suffer 
from  injuries  and  diseases  of  the  spinal  cord,  as  well  as  above  cicatricial  or 
other  forms  of  chronic  obstruction  of  the  bowel.  Such  masses  may  finally 
become  of  stony  hardness.  Foreign  bodies  swallowed,  if  sharp,  angular,  or 
49 


754  INJURIES   OF   SPECIAL  ABDOMINAL  OEGANS 

hooked,  may,  though  they  pass  the  stomach,  finally  lodge  and  remain  in  some 
lower  portion  of  the  gut.  Dr.  Eugene  Hodenpyl  informed  me  recently  that 
he  saw  total  obstruction  of  the  small  intestine  produced  by  half  a  dried  peach. 
Presumably  the  dried  and  shriveled  mass  was  swallowed  whole,  and  had  soon 
passed  the  pylorus,  entirely  undigested,  imbibing  water,  and  swelling  in  the 
small  intestine  to  such  a  size  that  it  completely  and  firmly  occluded  it.  The 
body  was  impacted  a  foot  from  the  ileo-cecal  junction  in  the  ileum.  The  ele- 
ment of  muscular  spasm  from  irritation  may  have  been  present  in  this  case. 
Bodies  of  considerable  size  tend  to  lodge  in  the  flexures  of  the  duodenum  and 
colon,  at  the  ileo-cecal  valve,  in  the  cecum,  and  just  above  the  anal  sphincters. 
Foreign  bodies  of  small  size — bird  shot,  pins,  grape  seeds,  etc. — may  enter 
and  remain  in  the  vermiform  appendix.  Such  an  occurrence  is  conceivably  a 
cause  of  appendicitis.  I  recall  two  cases :  in  one  of  them  a  bird  shot  was  in 
the  appendix,  in  the  other  a  pin.  There  was  no  reason  to  believe  that  the  for- 
eign bodies  were  the  cause  of  the  appendicitis  in  either  case.  Murphy  buttons 
do  not  cause  obstruction ;  the  buttons  are  perforated  Avith  numerous  holes ;  the 
contents  of  the  small  gut  are  fluid.  The  colon  is  large  enough  for  the  button 
to  pass. 

Diagnosis. — The  diagnosis  of  foreign  bodies  in  the  intestine  may  be  simple 
or  impossible.  If  it  is  known  that  the  patient  has  swallowed  a  foreign  body 
which  has  not  passed,  if  an  abdominal  operation  has  been  performed,  or  if  there 
is  a  definite  history  of  gall-stones,  the  diagnosis  may  be  clear ;  if  no  such  his- 
tory exists,  no  diagnosis  will  be  made  until  an  operation  is  done  for  intestinal 
obstruction,  or  for  localized  or  diffuse  peritonitis  from  ulceration  and  perfora- 
tion, when  the  body  may  be  discovered  in  the  gut,  or  in  an  abscess.  The  ob- 
structive symptoms  caused  by  foreign  bodies  vary  from  the  slightest  grades  of 
stenosis  to  complete  intestinal  obstruction.  If  a  stricture  of  the  bowel  exists, 
simple  or  malignant,  a  small  foreign  body  may  cause  complete  obstruction.  If 
a  foreign  body  is  large  and  hard  and  the  abdominal  wall  thin,  it  may  be  pal- 
pable through  the  abdominal  wall.  Large  masses  of  hardened  fecal  matter 
in  the  colon  give  the  signs  of  a  tumor  connected  with  the  colon  often  of  con- 
siderable size ;  they  may  remain  in  situ  for  weeks.  They  are  accompanied  by 
a  history  of  constipation  of  the  bowels,  sometimes  followed  by  diarrhea.  They 
very  rarely  cause  the  symptoms  of  intestinal  obstruction.  They  may  often 
be  recognized  from  the  history  of  the  case,  from  their  situation  in  the  colon, 
and  from  the  fact  that  the  mass  can  be  indented  with  the  fingers  and  retain 
its  shape  like  putty.  The  finally  efficient  action  of  purgatives  and  of  carefully 
given  high  enemata  usually  establishes  the  diagnosis.  The  symptoms  pro- 
duced by  foreign  bodies  which  cause  ulceration  and  final  perforation  may  be 
slight  or  absent  until  a  localized  or  general  peritonitis  occurs  or  may  be  pre- 
ceded by  the  symptoms  of  obstruction  of  the  bowel  more  or  less  marked.  Metallic 
foreign  bodies  may,  as  already  stated,  be  located  by  means  of  a  radiograph.  I 
recall  two  cases  of  foreign  bodies  in  the  gut  requiring  operative  removal.  The 
one  was  an  artery  clamp  left  by  a  surgeon  in  the  abdomen.     The  patient  con- 


GASTRIC   FISTULA  755 

tinned  to  complain  of  abdominal  pain  and  disturbances  of  digestion.  At  the 
end  of  a  year  or  more  a  second  operation  was  done.  The  clamp  was  found  and 
removed.  The  handles  of  the  clamp  had  ulcerated  through  into  the  small 
gut  and  were  much  eroded;  the  rest  of  the  instrument,  including  the  jaws,  lay 
outside  the  intestine  embedded  in  adhesions. 

The  second  case  I  saw  in  the  service  of  Dr.  Robert  Abbe  at  Roosevelt  Hos- 
pital. An  old  woman  entered  the  hospital  with  a  large  inflammatory  mass  in 
her  right  iliac  fossa ;  incision  opened  an  abscess  communicating  with  the  cecum. 
A  chicken  bone  of  considerable  length  lay  partly  in  the  abscess,  partly  in  the 
cecum. 

I  recently  operated  upon  an  old  lady  who  had  had,  when  I  first  saw  her, 
symptoms  of  intestinal  obstruction  from  obturation  for  five  days.  I  removed 
a  large  gall-stone  from  the  jejunum  which  completely  occluded  the  gut.  The 
operation  might  have  been  successful,  but  the  patient  had  been  left  too  long 
unrelieved,  and  died  from  shock. 

Gastric  Fistula. — A  gastric  fistula  may  open  through  the  abdominal  wall. 
Rarely  a  fistulous  communication  may  exist  between  stomach  and  the  trans- 
verse colon  or  duodenum,  rarely  the  ileum.  If  into  the  duodenum,  no  symp- 
toms referable  to  the  fistula  are  likely  to  develop.  If  into  the  ileum,  the  nutri- 
tion of  the  individual  may  suffer.  A  fistulous  communication  between  the 
stomach  and  the  kidney  w7as  reported  as  a  single  undoubted  case,  verified  at 
autopsy  by  Henry  Morris.  External  gastric  fistula?,  except  such  as  are  made 
intentionally  or  follow  accidentally  a  surgical  operation  upon  the  stomach,  are 
rare.  Wounds  and  perforations  of  the  stomach  are  much  more  apt  to  be 
followed  by  generalized  or  local  peritonitis.  Still,  such  fistula?  do  occasion- 
ally occur  as  the  result  of  stab  and  gunshot  wounds  of  the  stomach ;  perforations 
of  the  stomach  from  within  from  gastric  ulcer  or  foreign  bodies.  The  external 
fistula?  are  nearly  always  of  the  anterior  wall  of  the  stomach  in  the  epigas- 
trium or  near  the  costal  border  upon  the  left  side.  Rare  fistula?  opening 
through  the  pleura  and  chest  have  been  reported.  The  mucous  membrane  of 
the  stomach  may  be  adherent  to  the  skin,  or  there  may  be  a  canal  of  greater 
or  less  length,  or  a  cavity  of  some  size  between  the  skin  and  the  stomach.  The 
symptoms  of  gastric  fistula  consist  of  the  escape  of  stomach  contents,  gastric 
juice,  and  mucus  through  the  fistula.  According  to  the  size  of  the  opening, 
the  discharge  may  be  large  or  small.  Usually  the  material  is  acid  in  reac- 
tion. If  a  cavity  exists  between  the  skin  and  the  stomach,  and  the  stomach 
orifice  is  small,  the  discharge  may  be  mixed  with  pus  and  mucus,  and  be  neu- 
tral, even  alkaline  in  reaction.  Usually  the  skin  becomes  irritated  around  the 
fistulous  opening.  Eczema  develops.  The  gastric  juice  may  digest  the  skin, 
causing  painful  ulceration.  Usually  the  diagnosis  of  external  gastric  fistula 
is  very  simple.  If  the  orifice  is  small,  it  may  be  difficult  to  tell  whether  the 
fistula  communicates  with  the  stomach  or  the  duodenum.  Above  the  orifice 
of  the  ductus  communis  in  the  duodenum,  the  contents  of  the  bowel  cannot  be 
distinguished  from  that  of  the  stomach.     In  the  latter  case  colored  fluids  swal- 


756  INJURIES    OF    SPECIAL   ABDOMINAL   OEGANS 

lowed  (methylene  blue)  will  usually  appear  very  soon  in  the  fistula ;  in  the  for- 
mer, only  after  an  interval.  If  gastric  fistula  is  large,  so  that  the  food  is  not 
properly  retained  in  the  stomach,  the  general  nutrition  will  suffer ;  otherwise 
not.  From  very  large  openings  death  may  ensue  from  inanition.  The  ordinary 
operative  fistulas  of  the  stomach  close  of  themselves  if  let  alone.  Pathological 
ones,  if  of  considerable  size,  and  especially  if  the  mucous  membrane  of  the 
stomach  becomes  adherent  to  the  skin,  do  not.  In  cases  of  gastric  fistula  into 
the  transverse  colon,  if  the  orifice  is  of  some  size,  nutrition  may  suffer  severely. 
Undigested  food,  milk,  or  colored  fluids  will  appear  speedily  in  the  stools  after 
swallowing  them.  There  may  be  actual  fecal  vomiting  from  the  entrance  of 
scybalous  masses  into  the  stomach  from  the  colon.  Air  or  fluids  may  usually 
be  injected  from  the  rectum  into  the  stomach,  and  recognized  by  percussion  or 
the  use  of  the  stomach-tube.     The  general  nutrition  suffers  severely. 

Intestinal  Fistulae. — Fistula?  of  the  intestine  below  the  stomach  are  much 
more  frequent  than  the  gastric  variety.  They  may  open  upon  the  skin  or  inter- 
nally into  other  coils  of  intestine  or  into  adjacent  hollow  organs. 

External  Fistulje. — Intestinal  fistula?  opening  upon  the  skin  occur  from 
a  variety  of  causes.  They  may  he  made  by  surgeons  for  therapeutic  purposes. 
In  order  to  feed  the  individual — jejunostomy  in  certain  cases  of  cancer  of  the 
stomach,  etc.  In  order  to  afford  escape  to  intestinal  contents,  either  tempo- 
rarily or  permanently,  in  cases  of  acute  and  chronic  intestinal  obstruction,  or 
paralysis  of  the  gut,  or  for  the  purpose  of  applying  local  treatment  to  the 
interior  of  the  gut  in  cases  of  disease  (appendicostomy  in  chronic  colitis). 
They  may  arise  accidentally  from  incised  stab  or  gunshot  wounds  of  the  abdo- 
men when  the  intestine  becomes  prolapsed  or  adherent  at  the  point  of  injury 
to  the  edges  of  the  wound,  or  when  a  localized  peritonitis  and  abscess  is  formed 
as  the  result  of  open  wounds  or  subcutaneous  ruptures  of  the  gut  which  per- 
forates the  abdominal  wall  or  is  incised.  As  already  alluded  to,  an  extra- 
peritoneal fistula  is  possible  in  certain  situations.  Further,  as  the  result  of 
operations  upon  the  intestinal  tract  when  sutures  placed  in  the  gut  fail  to 
hold,  or  when  the  sutured  or  ligated  structures  become  necrotic  (appendical 
stumps),  and  that  whether  the  abdominal  wound  is  closed  or  not.  Further, 
from  accidental  unrecognized  injury  of  the  normal  or  diseased  intestine  dur- 
ing abdominal  operations.  Fistula?  also  result  from  a  great  variety  of  intra- 
abdominal processes — foreign  bodies,  which  perforate  the  gut,  ulcerative  and 
gangrenous  processes  of  the  intestine  (appendicitis,  typhoid  fever)  ;  such  fistula3 
are  commonly  preceded  by  a  localized  peritonitis  and  abscess  which  perforates 
outwardly ;  malignant  tumors  of  the  gut  which  invade  the  abdominal  wall  and 
ulcerate;  tuberculosis  and  actinomycosis  of  the  intestine.  Similar  processes 
originating  in  the  peritoneum  or  in  the  abdominal  wall  may  at  once  invade  the 
belly  wall  and  the  gut,  may  break  down,  and  result  in  fistula.  Unoperated 
strangulated  hernia?  which  fail  to  kill  by  obstruction  or  peritonitis  may  result 
in  an  intestinal  fistula.  The  gut  becomes  gangrenous,  is  perforated,  its  contents 
escape  into  the  surrounding  coverings  of  the  hernia,  a  phlegmonous  inflamma- 


INTESTINAL   FISTULA  757 

tion  follows  with  perforation  of  the  skin,  and  discharge  of  intestinal  contents 
outwardly.  Life  may  be  saved  with  the  spontaneous  formation  of  an  artificial 
anus.  In  very  rare  cases  complete  spontaneous  cure  may  result.  A  case  of 
this  kind  was  in  my  care  at  the  Roosevelt  Hospital.  The  history  is  so  unusual 
that  I  relate  it  briefly : 

An  old  man,  aged  sixty-eight,  was  admitted  to  the  hospital.  Five  days  before, 
a  left-sided  scrotal  hernia  had  become  swollen,  painful,  and  irreducible.  Vom- 
iting, prostration,  abdominal  distention,  and  other  signs  of  intestinal  obstruc- 
tion followed.  He  remained  in  bed  and  sought  no  medical  aid  until  brought  to 
the  hospital.  His  general  condition  was  fairly  good.  Vomiting  had  ceased  the 
day  before,  since  when  the  swelling  of  the  scrotum  had  greatly  increased.  The 
scrotum  was  much  enlarged,  reddened;  the  skin  was  perforated  at  several  points; 
fecal  matter  was  escaping  freely  from  these  openings.  Under  ether  anesthesia,  in- 
cisions in  the  scrotum  opened  a  large  fecal  abscess  with  necrotic  walls.  The  cavity 
contained  a  loop  of  gangrenous  and  perforated  large  intestine  about  fourteen  inches 
in  length.  Identified  as  sigmoid  flexure.  The  external  ring  appeared  to  be  the 
point  of  constriction.  The  constriction  was  relieved  by  incision.  A  small  amount 
of  healthy  gut  pulled  out;  the  gangrenous  loop  was  cut  away,  and  the  ends  of 
healthy  gut  were  sewed  by  a  few  stitches  to  the  borders  of  the  ring  and  to  each 
other,  simply  to  prevent  their  retraction  into  the  abdomen.  Local  and  general 
conditions  seemed  to  render  an  effort  to  unite  and  return  the  divided  ends  unwise. 
After  the  establishment  of  this  artificial  anus  the  general  condition  of  the  patient 
improved  at  once;  slowly  the  sloughs  separated  from  the  scrotum,  and  it  was  found 
that  by  packing,  the  movements  of  the  bowels  could  be  partly  controlled.  After 
a  number  of  weeks  the  whole  raw  surface  became  covered  by  healthy  granulations, 
and  diminished  in  size  until  only  a  cavity  of  moderate  size  existed  opposite  the 
external  ring  in  the  groin.  The  old  man  began  to  have  an  occasional  natural  move- 
ment from  the  bowels  per  anum;  gradually  the  amount  of  fecal  matter  escaping 
through  the  groin  diminished,  and  finally  ceased.  The  wound  healed  and  the 
patient  left  the  hospital  quite  well  and  cured  of  his  hernia. 

Abscesses  which  form  in  the  vicinity  of  the  intestine  may  break  outwardly, 
and  into  the  intestine  as  well — i.  e.,  an  osteomyelitis  of  the  sacrum  or  ileum — 
and  result  in  intestinal  fistula.  While  fistula  may  connect  any  portion  of  the 
intestine  and  the  abdominal  wall,  certain  situations  are  favorite  sites — namely, 
the  right  iliac  region,  the  inguinal  regions,  and  the  umbilicus.  The  occurrence 
of  appendicular  abscess,  of  tuberculosis,  malignant  disease,  and  actinomycosis 
of  the  cecum  accounts  for  the  frequent  formation  of  intestinal  fistulse  in  the 
right  iliac  region.  Strangulated  inguinal  hernia  accounts  for  the  formation 
of  fistula  in  the  groin.  The  umbilicus  is  a  favorite  site  for  several  reasons.  It 
is  a  weak  place  in  the  belly  wall  through  which  many  intra-abdominal  inflam- 
mations perforate.  It  is  a  common  site  of  strangulated  hernia.  Omphalo- 
mesenteric fistula  opens  there.  (See  Omphalomesenteric  Fistula).  In  cases  of 
congenital  umbilical  hernia  the  division  of  the'  cord  may  create  a  fistula.  As  in 
the  case  of  the  stomach,  we  distinguish  fistulse  in  which  the  mucous  membrane 


758  INJURIES    OF   SPECIAL   ABDOMINAL  ORGANS 

of  the  gut  is  adherent  to  the  skin,  those  in  which  a  canal  of  some  length  exists 
between  the  skin  and  the  gut  lined  by  mucous  membrane,  rarely  by  skin,  or  most 
commonly  by  granulation  tissue ;  further,  those  in  which  a  cavity  of  some  size 
exists  communicating  with  the  intestine  and  with  the  skin.  These  distinctions 
are  important  from  a  prognostic  and  therapeutic  standpoint,  since  the  first 
variety  do  not  heal  without  operation.  The  others  may,  with  exceptions  to 
be  noted.  Intestinal  fistula?  may  be  large  or  small.  The  entire  intestinal  con- 
tents may  pass  through  the  fistula,  or  only  a  part  of  it ;  in  some  cases  so  small 
a  part  that  the  recognition  of  intestinal  contents  in  the  discharge  may  be  diffi- 
cult. When  the  bowel  evacuates  itself  entirely  through  the  fistula,  we  speak 
of  it  as  an  artificial  anus  (anus  praeternaturalis).  When  only  a  part,  as  a 
fecal  fistula.  The  quantity  discharged  through  the  fistula  depends  not  only 
upon  the  size  of  the  opening  in  the  gut,  but  very  largely  upon  the  patency  of 
the  gut  beyond  the  fistula.  If  the  lower  portion  of  the  gut  is  entirely  patent, 
a  large  fistula  may  discharge  but  little  fecal  matter.  If  not,  a  small  opening 
may  discharge  much  or  all  of  the  intestinal  contents.  The  patency  of  the 
lower  limb  of  the  gut  may  depend  upon  a  stricture  or  other  cause  of  obstruction 
situated  at  a  more  or  less  distant  point;  in  many  instances  it  depends  upon 
mechanical  conditions  affecting  the  intestine  in  the  immediate  vicinity  of  the 
fistula,  developed  as  the  result  of  the  fistula,  or  existent  at  the  time  the  fistula 
was  formed.  Inasmuch  as  the  future  history  of  these  cases  and  the  treatment 
depends  largely  upon  these  local  conditions,  it  seems  best  to  explain  them  here. 
When  a  fistulous  canal  of  some  length  lined  by  granulation  tissue  connects  a 
rather  deeply  placed  coil  of  gut  with  the  skin,  the  tendency  is  toward  ultimate 
spontaneous  healing;  when,  on  the  other  hand,  a  coil  of  gut  lies  just  beneath 
the  abdominal  wall  and  opens  by  a  larger  or  smaller  opening  upon  the  skin, 
the  conditions  are  different.  The  coil  is  acted  on  by  three  forces:  Direct  trac- 
tion by  the  mesentery,  peristalsis,  and  intra-abdominal  pressure.  No  matter 
how  flatly  the  coil  of  gut  may  have  been  applied  to  the  abdominal  wall  at  the 
time  the  fistula  was  formed,  the  mesentery  tends  to  draw  the  intestine  back  into 
the  abdomen;  under  favorable  conditions  spontaneous  cure  results.  In  other 
cases  the  area  of  gut  occupied  by  the  fistula  is  firmly  attached  to  the  abdominal 
wall;  the  pull  of  the  mesentery  will  draw  away  both  the  afferent  and  efferent 
limbs  of  the  intestinal  loop,  while  their  junction  remains  fixed.  Thus  very  soon 
an  angle  or  kink  is  formed  in  the  loop  whose  apex  is  at  the  fistulous  opening. 
The  mesenteric  attachment  of  the  loop  forms  a  bar  or  spur  of  mucous  mem- 
brane which  tends  to  diminish  the  size  of  the  gut  at  this  point,  and  therefore 
the  freedom  of  the  passage  of  intestinal  contents  through  the  natural  channel, 
and  to  encourage  its  escape  through  the  fistula.  Peristalsis  acts  to  force  the 
contents  of  the  afferent  loop  and  its  loosely  attached  mucosa  toward  the  fistu- 
lous opening.  Intra-abdominal  pressure  acts  similarly.  Prolapse  of  the  mucous 
membrane  of  the  afferent  loop  results.  Peristalsis  in  the  efferent  loop  tends  to 
draw  it  away  from  the  orifice.  A  continuance  of  these  forces  often  results  in 
complete  prolapse  of  the  mucous  membrane  of  the  afferent  loop,  and  even  of 


INTESTINAL   FISTUL2E  759 

its  junction  with  the  efferent  loop;  and  in  this  manner  a  fistula  of  moderate 
size  may  be  converted  into  an  artificial  anus.  In  the  meantime  the  lower 
portion  of  the  gut  shrinks  and  undergoes  partial  atrophy  from  disuse;  a  per- 
manent artificial  anus  is  established,  only  to  be  relieved  by  operation,  except  in 
very  rare  cases. 

The  local  and  general  results  of  fecal  fistula  and  of  artificial  anus  depend 
upon  two  factors — namely,  the  distance  of  the  fistula  from  the  stomach  and 
the  amount  of  intestinal  contents  escaping  through  the  unnatural  opening.  An 
artificial  anus  in  the  colon,  though  unpleasant,  does  not  in  itself  involve  impair- 
ment of  the  general  health.  The  same  may  be  true  of  an  opening  at  the  lowest 
point  of  the  ileum.  A  similar  condition  in  the  upper  part  of  the  small  intes- 
tine leads  to  inevitable  death  from  inanition.  The  nearer  the  stomach  the 
opening  lies  and  the  larger  the  escape  of  intestinal  contents  from  such  an  open- 
ing, the  greater  the  likelihood  of  imperfect  absorption  and  consequent  innutri- 
tion. These  facts  render  the  surgeon  extremely  unwilling  to  leave  an  exter- 
nal opening  in  the  small  intestine,  when  it  can  by  any  means  be  avoided.  When 
such  an  opening  exists,  the  question  of  whether  the  patient  is  holding  his  own 
can  be  determined  by  weighing  him  from  time  to  time,  and  the  probable  situa- 
tion of  the  fistula  may  be  inferred  from  the  results.  The  diagnosis  of  the  dis- 
tance of  an  intestinal  fistula  from  the  stomach  is  therefore  very  important. 
The  following  data  are  useful :  The  contents  of  the  small  gut  is  fluid ;  that  of 
the  colon  solid  or  semisolid.  The  contents  of  the  duodenum  and  jejunum  are 
bright  yellow  or  yellowish-green  in  color  from  the  presence  of  unchanged  bile 
pigment ;  these  pigments  alter  in  color  farther  down,  and  become  brown  or 
dark  brownish-green  in  the  large  intestine.  Upon  the  skin  the  contents  of  the 
small  intestine  are  irritating  and  even  destructive.  The  skin  becomes  inflamed, 
red,  and  excoriated ;  digestion  of  the  skin  takes  place.  I  have  seen  the  skin  of 
the  abdomen  destroyed  over  an  area  as  large  as  a  man's  hand.  These  ulcer- 
ations are  extremely  painful.  The  higher  up  the  lesion,  the  more  intense  the 
digestive  action.  In  fistula?  from  the  large  gut  this  digestive  action  is  absent ; 
eczema  and  dermatitis  are  usually  present.  The  contents  of  the  upper  part  of 
the  small  gut  is  odorless ;  lower  down  the  characteristic  fecal  odor  is  gradually 
developed.  Usually  the  recognition  of  a  fecal  fistula  offers  no  difficulties. 
The  escape  of  undigested  or  partly  digested  food — recognizable  under  the  micro- 
scope as  striped  muscle  fiber,  starch  granules,  vegetable  fiber,  etc. — is  easy.  Gas 
quite  commonly  escapes  from  such  fistula?.  When  the  fistula  is  very  small  and 
discharges  only  a  little  muco-pus  it  may  be  difficult.  The  odor  of  a  discharge 
is  not  characteristic,  since  any  pus  focus  near  the  intestine  may  be  infected 
with  colon  bacilli  and  have  a  fecal  odor.  Sometimes  by  feeding  a  patient 
methylene  blue  or  charcoal  these  substances  may  be  recognized  by  their  color 
when  they  appear  in  the  fistula.  The  formation  of  a  spur  can  be  detected  in 
case  the  fistula  will  not  admit  a  finger  by  introducing  two  probes,  one  into 
either  loop,  and  moving  them  about  to  feel  the  conformation  of  the  gut  between. 
When  operating  upon  the  intestines  for  the  purpose  of  closing  fistulas,  making 


760  INJURIES    OF   SPECIAL   ABDOMINAL   ORGANS 

anastomoses  between  adjacent  coils,  excluding  portions  of  intestine  which  are 
diseased  and  cannot  be  removed,  creating  a  permanent  artificial  anus  in  the 
sigmoid  -when  one  end  is  to  be  closed  and  returned  to  the  belly,  it  often  becomes 
essential  to  determine  which  is  the  upper  and  which  is  the  lower  limb  of  the 
loop.  If  the  case  is  one  of  an  old  artificial  anus,  or  if  a  large  part  of  the  intes- 
tinal contents  has  escaped  through  the  fistula,  the  differences  between  the 
two  are  striking.  The  lower  loop  is  smaller,  its  mucous  membrane  paler,  the 
intestine  is  empty  and  contracted.  The  upper  loop  is  larger,  contains  fecal 
matter  and  gas.  Prolapsed  mucous  membrane  on  the  abdominal  wall  belongs 
usually  to  the  upper  loop.  It  is  sometimes  possible  to  tell  by  inspecting  the 
prolapsed  mucous  membrane  of  a  coil  of  gut  whether  it  is  large  or  small  intes- 
tine. The  mucosa  of  the  small  gut  is  velvety  and  dull ;  that  of  the  large  intes- 
tine smooth  and  glistening.  These  characters  may  be  lost  in  mucous  mem- 
brane long  exposed  on  the  surface  of  the  abdomen.  When,  however,  after 
opening  the  belly,  the  intestines  are  found  matted  together  by  adhesions,  and  if, 
as  sometimes  happens,  several  coils  of  gut  communicate  with  the  fistula,  the 
question  may  not  be  so  simple.  It  is  sometimes  possible  by  irritating  the  peri- 
toneal surface  of  the  gut  to  excite  a  wave  of  peristalsis  which  gives  the  correct 
direction  of  the  fecal  current.  In  difficult  cases  this  has  not  in  my  experience 
been  of  much  use.  If  practicable  the  surgeon  may  follow  loop  after  loop  with 
his  fingers,  until  he  is  thus  led  to  the  duodeno-jejunal  junction  or  to  the  cecum, 
as  the  case  may  be.  If  the  coil  of  gut  is  free  from  adhesions,  its  direction  may 
be  determined  by  drawing  it  out  of  the  abdomen  and  having  it  held  straight, 
under  a  little  tension,  by  an  assistant.  The  surgeon  slips  his  thumb  and  fingers 
down  on  either  side  of  the  gut  in  the  direction  of  the  mesenteric  attachment, 
grasping  the  mesentery.  Twists  in  the  mesentery  can  thus  be  detected,  and 
after  they  are  unraveled,  the  position  of  the  coil  with  reference  to  its  mesen- 
teric attachment  serves  to  indicate  the  higher  and  lower  portion  of  the  coil 
respectively  (Rand,  Stimson,  Monks).  In  the  case  of  the  large  gut,  error  is 
likely  to  occur  in  the  sigmoid  flexure.  In  this  case  milk  injected  into  the 
rectum  will  uusally  appear  promptly  at  the  orifice  of  the  lower  loop  if  no 
obstruction  exists  in  the  rectum,  or  the  mesentery  of  the  loop  can  be  traced  down 
to  the  rectum,  care  being  taken  to  unravel  existing  twists.  In  spite  of  care  and 
skill,  mistakes  do  occur,  and  I  have  seen  experienced  and  skillful  surgeons 
close  off  the  wrong  end  from  the  intestinal  current  more  than  once.  The  con- 
sequences of  such  an  error  are  intestinal  obstruction,  which  may  or  may  not  be 
relievable  by  a  subsequent  operation. 

Internal  Intestinal  Fistulje. — Internal  intestinal  fistulse  may  form 
between  different  portions  of  the  intestine,  or  between  the  intestine  and  other 
hollow  organs,  the  gall-bladder  and  gall-ducts,  the  kidney,  ureter  and  urinary 
bladder,  the  uterus,  and  very  rarely  the  Fallopian  tubes.  The  formation  of  the 
fistula  may  be  due  to  inflammatory,  ulcerative,  or  traumatic  lesions  of  the  intes- 
tine, or  may  originate  in  similar  lesions  of  hollow  organs  not  a  part  of  the 
intestinal  tract  which  perforate   into  the  intestine.      The  causes   of   internal 


INTESTINAL   FISTULA  761 

fistulse  between  different  portions  of  the  intestine  are  the  same  as  the  causes 
which  produce  external  fistula1,  as  already  described.  Usually  fistulse  form 
between  neighboring  viscera,  small  intestine  with  small  intestine  or  with  colon. 
Kidney  with  colon  or  duodenum.  Gall-bladder  and  gall-ducts  with  duodenum 
or  hepatic  flexure  of  the  colon.  Rectum,  sigmoid  flexure,  lower  coils  of  ileum, 
vermiform  appendix,  with  bladder,  uterus,  vagina. 

The  symptoms  produced  by  communications  between  adjacent  coils  of  gut 
may  not  be  recognizable.  If  the  opening  is  large  and  a  considerable  portion 
of  the  alimentary  tract  is  thrown  out  of  the  intestinal  current,  inanition  may 
result.  The  condition  may  be  suspected  from  the  passage  per  rectum  of  only 
partly  digested  food  too  soon  after  eating  to  have  traversed  the  entire  canal. 
Biliary  fistulse  between  the  gall-bladder  and  duodenum  or  colon  are  usually 
caused  by  the  pressure  and  ulceration  of  large  gall-stones  and  gradual  per- 
foration of  the  intestine.  During  their  formation  they  may  give  no  symptoms 
at  all  or  no  symptoms  which  can  be  differentiated  from  cholangitis,  cholecys- 
titis, localized  peritonitis,  etc.  The  establishment  of  a  fistula  between  the  gall- 
bladder or  ducts  and  the  duodenum  need  give  no  symptoms  of  itself.  The 
formation  of  a  fistula  from  the  biliary  passages  into  the  colon  will  lead  to  the 
imperfect  digestion  of  fats.  The  formation  of  fistulse  between  the  intestine 
and  the  female  genital  tract  is  very  frequent.  The  causes  are  labor,  especially 
instrumental  deliveries,  versions,  etc. ;  surgical  operations  upon  the  uterus, 
curettage,  etc. ;  accidental  injuries ;  ulcerations  from  cancer  of  the  uterus.  Very 
rarely  does  the  process  arise  in  the  intestine  itself,  and  is  then  commonly  due 
to  tuberculosis.  The  diagnosis  depends  upon  recognizing  the  escape  of  intes- 
tinal contents  from  the  vagina.  The  character  and  amount  of  the  discharge 
permit  a  judgment  to  be  formed  of  the  position  of  the  fistulous  opening  in  the 
gut.  (See  External  Fistulse.)  Examination  of  the  vagina  by  sight  and  touch 
permits  the  size  and  situation  of  the  fistula  to  be  recognized.  If  the  fistula 
communicates  with  the  uterus,  the  discharge  will  escape  through  the  cervix. 
Fistulse  between  the  intestine  and  the  urinary  tract  occur  between  the  gut  and 
the  kidney  or  its  pelvis,  between  the  ureter  and  the  colon  or  rectum  as  the 
result  of  the  intentional  acts  of  surgeons,  and  between  various  parts  of  the  gut 
and  the  urinary  bladder.  Fistulas  between  the  kidney  or  its  pelvis  and  the  gut 
are  rare.  They  occur  from  ulcerative  processes  set  up  by  kidney  stones  or  from 
destructive  inflammatory  processes  of  other  origins  in  the  kidney,  acute  abscess, 
pyonephrosis,  and  tuberculosis  of  the  kidney.  They  open  much  more  commonly 
into  the  colon  than  into  the  duodenum.  Urine  may  pass  into  the  intestine 
or  intestinal  contents  into  the  urinary  tract,  or  both.  The  diagnosis  has  occa- 
sionally been  confirmed  by  the  formation  of  an  external  fistula  as  well.  When 
urine  passes  into  the  intestine  the  diagnosis  is  to  be  made  from  the  passage  of 
urine  or  of  urinary  ingredients  in  considerable  quantities  per  rectum.  Urea, 
uric  acid,  etc.  If  the  escape  of  urine  into  the  gut  is  small,  or  if  the  fistula 
opens  into  the  duodenum,  reabsorption  of  the  urine  by  the  intestine  will  render 
the  findings  of  little  value,  since  urinary  ingredients  may  appear  in  the  feces 


762  INJURIES    OF   SPECIAL   ABDOMINAL   ORGANS 

in  small  quantities  when  no  fistula  exists.  In  the  few  cases  of  duodenal  fistula 
which  have  been  verified,  urine  has  sometimes  passed  into  the  stomach  and 
been  vomited,  as  have  renal  calculi.  When  intestinal  contents  enter  the  urinary 
tract,  the  consequences  are  always  serious ;  infection  of  the  urinary  apparatus 
is  inevitable ;  at  first,  a  descending  infection ;  later,  in  many  cases,  an  ascending 
infection  also.  Thus  cystitis,  followed  by  pyelitis,  pyelonephritis,  etc.,  often 
follows  the  constant  escape  of  intestinal  contents  into  the  bladder,  and  it  has 
been  found  that  implantation  of  the  ureters  into  the  sigmoid  flexure  of  the 
colon  is  regularly  followed  by  pyelitis  and  fatal  infection  of  the  kidney.  In 
order  to  recognize  the  condition  positively,  it  is  necessary  to  find  actual  intes- 
tinal contents  in  the  urine,  particles  of  meat  fiber,  starch  granules,  etc.  The 
mere  presence  of  a  fecal  odor  or  of  saprophytic  bacteria  in  the  urine  establishes 
nothing.  Even  the  presence  of  gas  in  the  bladder  is  not  conclusive,  since  gaso- 
genic  bacteria  may  reach  the  bladder  from  other  sources,  or  the  fermentation 
of  diabetic  urine  may  produce  the  same  condition.  The  diagnosis  might  be 
confirmed  by  giving  the  patient  methylene  blue  by  the  mouth;  this  produces  a 
blue  coloration  of  the  urine.  If  the  feces  were  stained  blue,  it  would  indicate 
the  passage  of  urine  into  the  intestine.  By  giving  the  patient  charcoal  by  the 
mouth,  its  presence  in  the  urine  would  indicate  the  passage  of  intestinal  con- 
tents into  the  urinary  passages.  By  far  the  largest  -number  of  intestinal  fistulse 
into  the  urinary  tract  are  connected  with  the  bladder.  In  about  half  the  cases 
the  fistula  communicates  with  the  rectum;  in  a  considerable  number  with  the 
sigmoid  flexure ;  less  often  with  the  lower  coils  of  ileum ;  rarely  with  the 
appendix  or  the  cecum.  The  causes  are  very  various.  Trauma,  tuberculosis, 
cancer  of  the  intestine,  abscesses  connected  with  the  intestine  which  rupture 
into  the  bladder  (a,  perforated  appendix,  for  example),  inflammatory  processes 
originating  in  the  prostate,  pericystitis,  etc.  The  symptoms  are  a  sudden  or 
gradual  development  of  cystitis ;  the  escape  of  gas  with  the  urine ;  further,  the 
identification  of  intestinal  contents  in  quantity  or  under  the  microscope.  If 
the  communication  is  with  the  sigmoid  or  rectum  much  or  nearly  all  the  urine 
may  pass  per  rectum.      (See  Genito-urinary  Organs.) 

Diagnosis  of  the  Complications  following  Abdominal  Operations. — The  com- 
plications occurring  after  operations  upon  the  interior  of  the  belly  may,  for 
purposes  of  description,  be  grouped  under  (1)  shock,  (2)  hemorrhage,  (3)  in- 
fection of  the  external  wound,  (4)  peritonitis,  (5)  intestinal  obstruction, 
(6)  pneumonia,  (7)  bleeding  from  the  alimentary  canal,  (8)  thrombosis  and 
embolism.  These  constitute  the  most  frequent  conditions  to  be  met  with  and 
recognized  ;  others  may,  of  course,  appear  under  special  circumstances  in  infinite 
variety. 

Shock. — Shock  after  extensive  and  prolonged  operations  upon  the  belly, 
or  after  slight  abdominal  operations  upon  patients  who  are  already  weakened 
by  peritonitis,  hemorrhage,  starvation,  or  other  cause,  may  be  so  severe  that 
the  patient  either  dies  upon  the  operating  table  or  does  not  regain  consciousness 
and  dies  in  a  few  hours  in  a  state  of  collapse.     The  symptoms  do  not  differ 


COMPLICATIONS    FOLLOWING    ABDOMINAL    OPERATIONS        763 

from  those  already  mentioned  under  "  shock."  The  heart  beats  more  and  more 
rapidly  and  feebly.  Respiration  is  shallow  and  slow  or  irregular.  The  ex- 
tremities and  the  forehead  are  cold.  The  cutaneous  and  mucous  surfaces  pale. 
The  body  is  bathed  in  a  clammy  sweat.  When  death  is  very  near,  the  pupils 
of  the  eyes  dilate.  If  the  patient  regains  consciousness  at  all,  cerebration  is 
sluggish  and  imperfect.  In  some  cases,  under  suitable  treatment,  the  patient 
rallies  a  little,  but  very  soon  fails  to  respond  to  stimulation,  and  dies  in  a 
few  hours.  Some  observers  describe  a  condition  under  the  title  "  Delayed 
Shock  "  such  that  the  patient  appears  to  bear  the  operation  well  or  to  rally 
from  the  shock  only  again  to  sink  and  die  after  twenty-four,  thirty-six,  or  forty- 
eight  hours.  I  believe  that  in  most  of  these  cases  the  death  has  been  due  to 
undiscovered  bleeding  or  to  a  very  intense  acute  sepsis.  Be  that  as  it  may, 
if  at  the  end  of  the  operation  the  pulse  has  been  of  fair  quality  and  not  above 
100  to  110  beats  per  minute,  or  if,  though  shocked,  the  patient  has  responded 
well  to  stimulation  and  has  maintained  a  pulse  of  fair  quality  and  of  a  falling 
rather  than  a  rising  frequency  for  twelve  to  twenty-four  hours,  a  progressive 
change  for  the  worse,  a  failing  heart  as  indicated  by  an  increasing  pulse  rate, 
waxy  pallor,  restlessness,  great  thirst,  marked  abdominal  pain  and  distention, 
repeated  vomiting,  coming  on  after,  an  interval  of  several  hours  or  a  day  of 
fairly  satisfactory  progress,  should  always  lead  the  surgeon  to  suspect  intra- 
abdominal bleeding,  peritonitis,  or  some  serious  complication  other  than  mere 
shock. 

Intra-abdominal  bleeding  produces  the  symptoms  described  under  Injuries 
of  the  Abdomen.  In  some  cases  the  surgeon  may  have  some  clew  to  the  source 
of  hemorrhage  from  the  character  of  his  operation,  the  position  of  his  ligatures, 
etc.  If  the  symptoms  are  marked  and  progressive,  reopening  of  the  belly  and 
control  of  the  bleeding  vessel  is  the  best  and  only  rational  treatment.  It  is 
perhaps  needless  to  state  that  saline  infusions  into  veins  should  not  be  given 
until  the  bleeding  is  controlled.  If  a  donor  is  obtainable,  direct  transfusion 
may  be  tried. 

Hemorrhage  from  the  Alimentary  Canal. — Vomiting  of  blood  or  pas- 
sage of  blood  per  rectum  may  of  course  follow  operative  measures  upon  the 
stomach  and  intestine.  Such  bleeding  may  also  take  place  from  causes  not 
entirely  clear — notably  after  operations  involving  resection  of  the  omentum 
and  mesentery,  and  strangulated  hernia  and  obstruction  of  the  gut  from  other 
causes.  In  some  of  these  cases  more  or  less  extensive  thrombosis  of  the  mesen- 
teric veins  has  been  discovered  at  autopsy;  in  other  cases,  anemic  necrosis  of 
the  mucous  membrane  of  the  gut  has  been  observed  (von  Eiselberg,  Kocher). 
Vomited  blood  exposed  to  gastric  digestion  resembles  coffee  grounds.  Blood 
retained  in  the  bowel  for  any  length  of  time  and  passed  per  rectum  resem- 
bles tar. 

In  conjunction  with  the  diagnosis  of  wound  infection  and  peritonitis,  some 
general  remarks  may  not  be  out  of  place.  Vomiting  after  abdominal  operations 
is  common  as  the  result  of  ether  anesthesia.     In  many  cases  it  is  confined  to 


764  INJURIES    OF    SPECIAL   ABDOMINAL   ORGANS 

the  first  few  hours,  and  ceases  soon  after  the  patient  regains  consciousness. 
In  others,  vomiting  at  intervals  continues  for  forty-eight  hours,  seldom  much 
longer  unless  some  complication  is  present.  Such  may  he  local  or  diffuse  peri- 
tonitis, intestinal  obstruction  from  adhesions,  paralysis  of  the  gut,  atonic  and 
temporary  or  inflammatory  and  permanent.  After  operations  upon  the  stomach, 
bleeding  into  the  stomach  will  produce  vomiting.  After  gastroenterostomy,  a 
vicious  circle  of  the  intestinal  current  may  cause  continued  and  fatal  emesis. 
A  preexistent  chronic  gastritis,  a  nephritis,  and  other  nonsurgical  affections 
will  have  to  be  considered  in  certain  cases.  A  continuance  of  vomiting  after 
two  or  three  days,  uncontrolled  by  complete  rest  of  the  stomach  and  by  gastric 
lavage,  arouses  the  anxiety  of  the  surgeon  and  demands  a  careful  search  for 
its  causation.  In  favorable  cases  patients  are  able  to  retain  small  doses  of  suit- 
able food  after  twenty -four  hours. 

Symptoms  Referable  to  the  Intestine. — A  certain  amount  of  atonic 
paralysis  of  the  gut  follows  operations  involving  much  handling  of  intestinal 
coils,  traction  upon  the  mesentery,  long  exposure  to  the  air,  suture  and  resec- 
tion of  the  intestine,  evisceration,  separation  of  extensive  adhesions,  etc.  There 
results  more  or  less  distention  of  the  bowel  with  gas,  moderate  tympanites  in 
some  cases,  and  abdominal  pain  of  bearable  intensity,  lasting  from  twenty-four 
to  forty-eight  hours.  Partly  owing  to  atony  of  the  bowel,  partly  to  inability  to 
use  the  abdominal  muscles  on  account  of  pain,  patients  do  not  evacuate  flatus 
per  rectum.  After  twenty-four  to  thirty-six  hours  this  power  is  usually  re- 
gained, and  gas  is  usually  expelled  naturally,  or  through  a  stomach-tube  left 
in  the  rectum.  Inability  to  move  the  bowels  may  last  much  longer.  Many 
surgeons  are  accustomed  on  the  third  dav  or  earlier  to  administer  calomel  in 
divided  doses  (gr.  \— |)  every  hour  for  six  to  eight  hours,  followed  by  enemata; 
if  no  movement  follows,  a  saline  laxative  is  given  by  the  mouth.  Such  pro- 
cedures are  followed  by  success  in  most  cases  unless  something  is  going  wrong. 
Still,  as  long  as  gas  passes  per  rectum  and  the  patient's  pulse  remains  below 
a  hundred  and  of  good  quality,  in  the  absence  of  marked  abdominal  pain  and 
distention  and  of  vomiting,  the  fact  that  the  bowels  do  not  move  for  four  or 
five  days  is  not  a  cause  for  serious  anxiety. 

Retention  of  Urine. — Retention  of  urine  is  common  during  the  first  days 
after  an  operation  on  the  belly.  It  occurs  both  in  men  and  women,  and  among 
the  latter  notably  after  operations  on  the  uterus,  ovaries,  and  tubes.  It  depends 
to  a  great  extent  upon  the  unaccustomed  necessity  of  performing  the  act  while 
lying  upon  the  back,  and  is  recovered  from  in  a  few  days.  After  a  serious 
operation,  but  little  urine  may  be  formed  for  the  first  twelve  hours.  If  no 
urine  has  been  passed  by  the  morning  following  the  operation,  and  no  desire 
to  urinate  has  been  expressed,  the  catheter  should  be  passed  at  eight-hour  inter- 
vals or  less  until  the  bladder  can  be  emptied  voluntarily. 

Temperature  after  Abdominal  Operatioxs. — A  moderate  rise  of  tem- 
perature during  the  first  thirty-six  hours  is  common  and  not  alarming.  Its 
height  and  duration  will  depend  upon  the  character  of  the  operation,  whether 


COMPLICATIONS   FOLLOWING   ABDOMINAL   OPERATIONS       765 

clean  or  done  for  an  inflammatory  condition,  upon  the  amount  of  intraperitoneal 
oozing,  the  extent  of  raw  surface  left  uncovered  by  peritoneum,  the  ability  of 
the  surgeon  to  remove  septic  materials  completely.  A  rise  of  temperature 
developed  after  a  number  of  days,  or  a  temperature  which  remains  elevated 
when  local  conditions  as  far  as  known  do  not  appear  to  account  for  it,  is  a 
cause  of  anxiety.  Very  often  a  patient  who  has  a  moderate  rise  of  temperature 
for  several  days  will  cease  to  have  fever  at  once  when  the  bowels  have  been 
thoroughly  moved.  A  most  important  fact  to  bear  in  mind  is  that  very  serious 
abdominal  conditions  may  exist  without  a  corresponding  rise  of  temperature, 
and  the  presence  or  absence  of  fever  is  not  a  reliable  guide  in  estimating  the 
gravity  or  progress  of  the  given  case.     (See  Peritonitis.) 

The  Pulse. — An  increase  in  the  pulse-rate  is  the  rule  after  abdominal 
operations.  The  rapidity  will  depend  upon  the  gravity  of  the  procedure,  the 
amount  of  shock  or  bleeding,  the  presence  or  absence  of  sepsis  at  the  time 
of  the  operation.  After  the  immediate  effects  of  the  operation  have  passed  off, 
a  pulse-rate  of  100  is  not  a  cause  for  anxiety.  A  pulse  which  remains  at  120 
and  shows  an  upward  tendency  is  ground  for  serious  consideration  in  the 
absence  of  pneumonia  or  some  factor  to  account  for  it ;  peritonitis,  either  local- 
ized or  spreading,  is  the  most  probable  explanation.  Sepsis,  a  degenerated 
heart  muscle,  with  feeble  or  imperfect  resistance  and  absence  of  an  efficient 
reparative  process,  are  also  to  be  thought  of.  When  the  pulse-rate  steadily 
creeps  up  from  120  to  140  and  150,  becomes  thready,  when  the  extremities 
become  cold  and  cyanotic,  the  forehead  bathed  in  a  clammy  sweat,  the  features 
pinched  and  drawn,  the  lips  blue,  the  eyes  dull,  the  patient  is  dying. 

Infection  of  the  External  Wound. — Infection  of  operative  wounds  of 
the  abdominal  wall  sometimes  occurs  after  operations  for  septic  intra-abdominal 
conditions.  In  these  cases  the  superficial  wound  will  probably  have  been  left 
entirely  open  or  partly  open  and  drained.  Some  infection  will  be  looked  for,  or 
at  least  will  create  no  surprise ;  its  presence  will  be  evident  on  inspection.  In- 
fection occasionally  follows  clean  operations ;  the  wound  will  have  been  sutured. 
No  drains,  or  small  rubber-tissue  drains  only,  will  have  been  introduced  at  the 
wound  angles,  and  removed  at  the  end  of  twenty-four  hours.  A  somewhat 
tardy  and  not  very  virulent  infection  of  such  wounds  sometimes  develops  dur- 
ing the  week  following  the  operation.  The  infection  very  rarely  invades  the 
peritoneum,  but  usually  forms  an  abscess  in  the  subcutaneous  wound  space, 
less  commonly  in  the  muscular  layers. 

In  these  cases  the  following  signs  and  symptoms  lead  the  surgeon  to  explore 
the  abdominal  wound.  The  immediate  effects  of  the  operation  have  passed  off, 
the  bowels  have  moved,  the  patient  does  not  vomit.  He  has  no  intra-abdominal 
pain.  He  has  a  vague  sense  of  discomfort.  His  countenance  is  not  cheerful. 
His  appetite  does  not  return.  His  tongue  remains  coated.  He  does  not  sleep 
well.  He  has  a  daily  rise  of  temperature — 99.5°  P.  in  the  morning,  100.5°  to 
101.5°  P.  in  the  evening.  His  pulse-rate  is  increased  to  95  to  105  beats  per 
minute.     Locally,  he  may  complain  of  moderate  discomfort  or  moderate  pain 


766  INJURIES    OF   SPECIAL   ABDOMINAL   ORGANS 

in  the  abdominal  wound.  Upon  inspecting  the  wound  the  suture  line  may 
be  reddened  or  appear  perfect.  There  may  be  a  visible  fullness  in  the  vicinity 
of  the  wound.  If  the  wound  edges  are  reddened,  a  drop  or  two  of  pus  may 
appear  through  the  stitch  holes  in  the  skin.  Upon  palpation  tenderness  will 
be  complained  of  when  gentle  pressure  is  made  on  the  wound  edges.  Fluctua- 
tion will  not  usually  be  appreciated.  Upon  opening  the  wound  several  condi- 
tions may  be  found.  A  few  drains  of  blood-stained  pus  may  be  evacuated ;  the 
separated  wound  surfaces  will  show  but  slight  signs  of  infection ;  there  may 
be  small  areas  of  fat  necrosis  here  and  there,  notably  at  the  sites  of  ligatures. 
In  other  cases  merely  a  broken-down  blood  clot  will  be  evacuated.  In  still 
others  a  quantity  of  thin,  brownish-yellow  fluid  containing  many  fat  drops 
will  escape  (fat  necrosis).  Signs  of  distinct  infection  may  be  absent.  In 
more  severe  cases  the  subcutaneous  tissues  will  appear  superficially  necrotic 
and  infiltrated.  If  the  infection  is  in  the  intermuscular  planes,  removal  of 
muscle  sutures  will  evacuate  a  greater  or  smaller  quantity  of  pus.  Under  suit- 
able treatment  (relief  of  tension  by  removing  sutures,  free  drainage)  such 
infections  subside  rapidly.  The  patient's  general  condition  improves  at  once, 
fever  disappears,  etc.  The  wound  becomes  clean  in  a  few  days,  and  may  be 
sutured  or  strapped. 

Peritonitis. — Following  abdominal  operations  both  for  septic  and  clean 
conditions,  peritonitis  is  the  most  justly  dreaded  of  complications.  It  may 
simply  be  a  continuance  of  the  original  process  for  which  the  operation  was 
done,  or  may  arise  from  errors  in  surgical  technic  not  always  to  be  guarded 
against  even  by  the  most  careful  surgeons.  It  is  most  apt  to  occur  in  those 
cases  whose  powers  of  resistance  have  been  greatly  diminished  by  profound 
anemia,  by  chronic  alcoholism,  malignant  disease,  and  other  depressing  con- 
ditions. It  is  produced  by  inadequate  removal  or  drainage  of  septic  foci  at 
the  time  of  operation,  and,  as  stated,  in  clean  cases  by  errors  in  aseptic  technic. 
In  the  given  case  peritonitis  may  assume  any  of  the  forms  already  described 
under  Peritonitis  from  infection  with  pyogenic  bacteria.  Clinically  it  is  most 
important  to  distinguish  between  a  diffuse  purulent  peritonitis  without  limiting 
adhesions  and  a  localized  process  with  the  formation  of  one  or  more  definite 
loculi  of  pus  in  the  abdomen.  The  cases  of  the  first  class,  if  post-operative, 
are  almost  invariably  fatal.  Those  of  the  second  may  often  be  saved  by  prompt 
reopening  of  the  belly. 

The  s}miptoms  and  signs  of  the  two  types  do  not  materially  differ  from 
those  already  described  under  Peritonitis.  The  characters  of  the  diffuse  form 
may  be  briefly  recapitulated.  If  peritonitis  existed  at  the  time  of  operation, 
the  symptoms  and  signs  will  continue  and  grow  worse.  If  not,  it  may  be 
forty-eight  hours  or  more  after  the  operation  before  definite  symptoms  appear. 
They  will  be  abdominal  pain,  rigidity  and  distention,  restlessness,  anxiety,  a 
coated  tongue,  a  dry  skin,  repeated  vomiting,  at  first  of  bile-stained  fluid,  later 
of  intestinal  contents  of  a  dirty  brown  color  and  fecal  odor.  The  vomiting, 
at  first  violent,  ceases  to  be  so  later,  when  brown  fluid  pours  out  of  the  patient's 


COMPLICATIONS   FOLLOWING   ABDOMINAL   OPERATIONS       767 

mouth  in  quantity  without  apparent  effort.  There  is  absolute  constipation. 
A  progressively  rapid  heart,  a  pulse  growing  steadily  more  feeble,  compressible, 
and  rapid  until  the  end.  An  elevation  of  temperature  may  be  absent  in  the 
worst  cases.  In  others  fever  of  very  variable  degrees  of  intensity  Avill  be  present, 
and  may  rise  to  10G°  to  107°  F.  a  few  hours  before  death.  Generally  speak- 
ing', a  marked  rise  of  temperature  on  the  second  or  third  clay,  which  continues 
and  becomes  of  septic  type,  is  strongly  suggestive  of  peritonitis  unless  some 
other  complication  is  present  to  explain  it.  The  external  wound  may  be  nor- 
mal in  appearance.  There  may  be  redness  of  the  skin  and  pus  in  the  wound. 
The  wound  edges  from  the  skin  to  the  peritoneum  may  be  gangrenous.  It 
very  rarely  happens  that  reopening  the  belly  in  cases  of  diffuse  septic  peri- 
tonitis following  operation  is  successful  in  saving  life.  One  of  the  worst  signs 
in  these  cases  is  total  paralysis  of  the  gut,  appreciable  on  opening  the  belly. 

Localized  Peritonitis. — Localized  peritonitis  with  the  formation  of  a  walled- 
off  abscess,  or  of  the  progressive  fibrino-purulent  type,  may  follow  any  surgical 
operation  upon  the  belly.  It  may  be  due  to  the  same  causes  as  the  diffuse 
form.  In  many  cases  it  follows  imperfect  removal  or  drainage  of  septic  foci, 
or  the  giving  away  of  sutures  and  slow  leakage  of  septic  products  from  some 
sutured  viscus  (gall-bladder,  stomach,  intestine,  urinary  bladder,  appendical 
stump),  sometimes  the  breaking  down  of  a  previously  infected  retroperitoneal 
gland  or  portion  of  infected  omentum.  The  signs  and  symptoms  are  those 
described  under  Peritonitis.  The  continued  vomiting,  fecal  vomiting,  intense 
prostration,  general  rigidity  and  distention,  absolute  constipation,  and  rapidly 
failing  heart  of  diffuse  peritonitis  are  wanting.  The  local  signs  of  pain, 
rigidity,  and  tenderness  are  present,  together  with  the  general  symptoms  of 
sepsis  of  a  more  or  less  acute  type.  The  patient  is  ill,  and  becomes  more  ill 
from  day  to  day.  There  is  usually  fever,  moderate  or  high.  The  pulse-rate 
is  increased.  Leucocytosis  with  relative  increase  of  polynuclear  leucocytes  is 
present  in  nearly  all  cases.  These  data,  together  with  the  local  signs  and 
symptoms,  must  furnish  the  operative  indications  in  the  individual  case. 

Pneumonia. — Pneumonia,  usually  of  the  lobular  type,  is  not  an  uncom- 
mon sequence  of  operations  upon  the  belly.  It  is  probably  more  frequent  here 
than  after  other  operations.  In  some  instances  it  is  attributable  to  the  anes- 
thetic or  to  the  aspiration  of  septic  material  during  anesthesia.  In  others  it 
is  to  be  regarded  as  a  part  of  a  general  septic  process ;  in  these  cases,  when  death 
occurs,  the  pneumonia  is  hardly  to  be  regarded  as  more  than  a  contributory 
causative  factor.  For  the  signs  and  symptoms  of  broncho-pneumonia  the  reader 
is  referred  to  works  on  General  Medicine.  Pneumonia  following  surgical 
operations  is  recovered  from  in  a  large  percentage  of  cases.  In  a  good  many 
instances  it  is  difficult  to  say  at  first  whether  the  process  is  a  pneumonia  or 
an  intense  congestion  of  the  lungs  with  edema  and  a  more  or  less  acute  bron- 
chitis. 

Thrombosis  and  Embolism. — Thrombosis  of  the  external  iliac,  less  often 
of  the  common  iliac  veins  is  a  complication  of  operations  upon  the  belly  in 


768  INJURIES    OF    SPECIAL   ABDOMINAL   ORGANS 

a  pretty  large  number  of  cases — perhaps  in  one  per  cent  of  abdominal  opera- 
tions. I  have  seen  it  after  appendicitis  more  often  than  after  other  operations. 
I  have  rarely  seen  it  follow  operations  for  acute  appendicitis  with  abscess,  peri- 
tonitis, or  other  acute  lesion.  It  has  usually  followed  clean  interval  cases  dur- 
ing convalescence,  when  the  general  condition  of  the  patient  was  good  and  the 
wound  healed  by  primary  union.  For  reasons  not  at  all  clear,  it  occurs  upon 
the  left  side  of  the  body  in  all  but  a  very  small  percentage  of  the  cases.  It  is 
rare  before  the  end  of  the  first  week,  and  may  occur  as  late  as  a  month  after 
operation.  In  a  recent  case,  phlebitis  and  thrombosis  of  the  left  common  iliac 
vein  occurred  six  weeks  after  cholecystectomy  for  pressure  necrosis  of  the  gall- 
bladder due  to  impaction  of  a  very  large  stone  in  the  cystic  duct ;  the  case  was 
complicated  by  empyema  in  the  right  pleura.  The  phlebitis  and  thrombosis 
antedated  the  empyema  by  several  weeks.  The  patient  recovered.  The  signs 
and  symptoms  are  rapid  swelling  and  edema  of  the  entire  lower  extremity, 
accompanied  by  moderate  or  severe  pain  and  discomfort,  and  usually  a  moder- 
ate rise  of  temperature  and  an  accelerated  pulse.  If  the  common  iliac  vein 
is  thrombosed  in  men  the  scrotum  will  also  become  swollen  and  edematous.  The 
femoral  vein  may  be  palpated  as  a  tender,  hard  cord  in  Scarpa's  triangle,  as 
large  as  a  man's  thumb.  Tenderness  and  sometimes  a  sense  of  resistance  can 
usually  be  traced  above  Poupart's  ligament  into  the  pelvis.  Complete  though 
slow  recovery  is  the  rule.  A  few  of  these  cases  are  preceded  or  followed  by 
pulmonary  embolism.  In  some  cases  there  are  no  symptoms  except  sudden, 
instant  death.  In  others  the  patient  is  suddenly  seized  with  intense  precordial 
distress  and  dyspnea.  Progressive  heart-failure  may  end  life  in  minutes  or 
hours.  A  few  cases  recover.  (For  the  diagnosis  of  "  Septic  Pylephlebitis  of 
the  Portal  Vein,"  see  Diseases  of  the  Liver.) 

Intestinal  Obstruction  following  Abdominal  Operations. — Intes- 
tinal obstruction  may  follow  operations  upon  the  belly  at  any  time  during 
convalescence  or  after  long  delay  and  a  prolonged  period  of  health.  The  first 
varietv  alone  will  be  discussed  in  this  section.  A  common  cause  is  the  formation 
of  a  sharp  kink  in  a  coil  of  gut  maintained  in  position  by  the  rapid  adhesion 
of  adjacent  peritoneal  surfaces,  and  favored  by  intestinal  atony,  peritoneal 
irritation,  and  peritonitis.  It  is  certain  that  intraperitoneal  gauze  packings 
introduced  as  drains  may  favor,  and  actually  produce,  this  form  of  obstruction. 
Twists  and  kinks  may  be  produced  by  the  surgeon  when  handling  or  reducing 
prolapsed  coils  into  the  abdomen.  Volvulus  may  form  spontaneously.  Slits 
in  the  mesentery  or  omentum  may  lead  to  an  internal  hernia,  as  may  adhesion 
between  adjacent  coils  of  gut  with  the  formation  of  an  orifice  or  pocket  into 
which  other  coils  find  their  way  and  become  strangulated.  Old  adhesions  and 
bands  may  be  responsible  for  the  condition  as  well  as  new.  Sometimes  obstruc- 
tion may  be  caused  directly  by  the  operation,  as  when  the  transverse  colon  is 
directly  compressed  after  the  operation  of  anterior  gastroenterostomy,  or  as 
when  an  intestinal  anastomosis  produces  an  orifice  or  pocket  into  which  other 
coils  enter.     Intestinal  paralysis  due  to  peritonitis  or  to  handling  of  the  gut, 


COMPLICATIONS    FOLLOWING    ABDOMINAL    OPERATIONS       769 

traction  on  its  mesentery,  etc.,  as  already  mentioned,  may  cause  not  only  tem- 
porary but  permanent  paralysis  and  obstructive  symptoms.  (For  further  de- 
tails of  causation,  see  Intestinal  Obstruction.)  In  the  given  case  obstruction 
must  be  thought  of  when  vomiting  continues  after  forty-eight  hours  and  grows 
more  frequent  in  spite  of  rest  for  the  stomach  by  giving  no  food  by  the  mouth. 
When  no  gas  passes  per  rectum,  when  abdominal  distention  is  progressive,  when 
in  spite  of  eneiuata  and  gastric  lavage  the  vomiting  becomes  bile-stained  and 
finally  fecal  and  the  bowels  cannot  be  moved,  obstruction  certainly  is  present, 
either  mechanical  or  paralytic.  Together  with  these  symptoms  there  will  be 
abdominal  pain  and  tenderness.  The  presence  of  fever  suggests  peritonitis 
rather  than  mechanical  obstruction.  (See  also  Peritonitis.)  If  the  obstructive 
symptoms  occur  during  the  early  days  after  operation,  the  surgeon  may  some- 
times be  at  a  loss  to  distinguish  the  condition  from  peritonitis,  or  from  the 
not  infrequent  cases  in  which  both  conditions  exist.  More  lives  will  be  saved 
by  reopening  the  belly  early  than  by  delay.  If  peritonitis  and  paralysis  of  the 
gut  are  found,  the  patient  will  die,  but  he  will  have  been  given  the  best  possible 
chance.  If  mechanical  obstruction  exists,  relief  is  possible  by  early  operation 
in  many  cases.  When  the  obstructive  symptoms  develop  after  convalescence 
appears  to  be  established  at  an  interval  of  a  week,  a  fortnight,  or  more,  the 
likelihood  of  peritonitis  may  be  regarded  as  remote.  Operation  should  be  done 
as  soon  as  the  diagnosis  can  be  made,  and  before  the  symptoms  become  urgent. 
A  few  hours'  delay  may  find  the  patient  in  a  condition  of  collapse  such  that 
no  operation  is  possible. 

The  two  following  brief  history  abstracts  illustrate  the  good  results  of 
immediate  interference  and  the  fatal  results  of  delay:  I  operated  upon  a  young 
woman  for  acute  appendicitis,  with  perforation  and  a  localized  abscess,  the 
wound  being  left  partly  open  and  drained.  Normal  convalescence  up  to  the 
fourteenth  day.  On  that  day  acute  abdominal  pain,  frequently  repeated  and 
uncontrollable  vomiting  of  bile-stained  fluid.  Progressive  acceleration  of  pulse- 
rate  and  slight  tympanites.  Operation  by  enlarging  the  former  wound  six 
hours  after  the  first  symptoms  of  obstruction  appeared,  disclosed  a  coil  of  ileum 
twelve  inches  from  the  cecum,  sharply  kinked  and  held  by  recent  adhesions. 
The  intestine  above  the  kink  dilated,  below  collapsed.  Adhesions  easily  sepa- 
rated with  the  fingers.  Gas  seen  to  pass  freely  by  the  former  obstruction. 
Wound  partly  closed.     No  further  obstructive  symptoms.     Normal  recovery. 

The  second  case  was  a  little  boy  aged  ten.  Acute  appendicitis;  operation. 
Perforated  appendix.  Progressive  fibrino-purulent  peritonitis  not  far  ad- 
vanced. Appendix  removed ;  infected  areas  of  peritoneum  washed.  Gauze 
drainage.  Rapid  wound  healing.  Normal  convalescence  up  to  the  fifteenth 
day.  On  the  night  of  that  day  sudden  violent  abdominal  pain  and  repeated, 
uncontrollable  vomiting.  Acceleration  of  pulse-rate  and  prostration.  For  rea- 
sons which  need  not  be  specified,  I  was  not  called  until  the  following  morning, 
and  was  unable  to  reach  the  patient  until  noon.  At  this  time  the  child  was 
in  collapse,  nearly  pulseless.  Temperature  subnormal.  Extremities  cold;  cya- 
50 


770  INJURIES    OF    SPECIAL   ABDOMINAL   ORGANS 

nosis  of  the  face  and  fingers.  Fecal  vomiting  every  few  minutes.  Abdomen 
a  little  distended,  not  markedly  tender.  Condition  of  patient  such  that  no 
operation  could  have  been  borne.  Active  stimulation  and  high  enemata  of  no 
avail.     Patient  became  unconscious  at  1.30  p.m.  and  died  at  2  p.m. 

The  following  case  history  illustrates  intestinal  obstruction  from  ancient 
bands  and  adhesions :  The  obstructive  symptoms  came  on  rather  gradually, 
and  the  obstruction  did  not  become  complete  for  many  days.  For  reasons  not 
entirely  clear  to  myself  at  the  present  time,  I  failed  to  appreciate  the  gravity 
of  the  situation  until  the  patient  was  very  ill,  and  my  bad  judgment  in  this 
case  nearly  cost  the  patient  his  life.  Since  this  man  left  the  hospital  I  have 
seen  him  at  intervals ;  he  remains  in  good  health. 

Acute  Intestinal  Obstruction  from  Adhesion  Bands  following  Appendec- 
tomy.— A  man,  aged  thirty  years,  who  entered  the  Roosevelt  Hospital  on 
January  8,  1900,  with  the  following  history:  Fifteen  years  before  he  had  a 
severe  attack  of  illness,  which  seems  to  have  been  due  to  an  inflammation  of  the 
vermiform  appendix.  He  remained  well  after  recovery  from  this  attack  until 
five  months  ago,  when  he  had  a  typical  attack  of  appendicitis,  severe  in  char- 
acter, confining  him  to  his  bed  for  many  days  and  terminating  in  an  imperfect 
recovery,  the  region  of  the  appendix  having  remained  tender  upon  pressure 
ever  since.  Three  weeks  ago  he  had  another  severe  attack,  accompanied  by 
the  formation  of  a  tumor  in  the  right  iliac  fossa.  Since  then  he  has  lost 
strength  and  flesh,  and  has  constantly  suffered  from  considerable  discomfort, 
referred  to  the  region  of  the  appendix. 

Upon  admission  to  the  hospital  his  evening  temperature  was  100°  F. ;  pulse, 
84.  There  was  tenderness  on  pressure  and  a  slight  sense  of  resistance  to  be 
felt  over  the  appendix.  He  remained  under  observation  until  January  20th, 
during  which  time  he  had  a  slight  evening  rise  of  temperature.  The  local 
conditions  remained  about  the  same.  Upon  January  20th  the  abdomen  was 
opened  by  the  intermuscular  incision  of  McBurney.  The  cecum  was  found  to 
be  firmly  adherent  upon  its  outer  and  posterior  surfaces  to  the  peritoneum 
covering  the  iliac  fossa.  After  a  rather  tedious  dissection,  a  small  abscess  was 
opened,  which  contained  about  half  a  dram  of  pus.  This  abscess  was  found 
to  communicate,  on  the  one  hand,  with  the  open  end  of  an  appendix  about  an 
inch  in  length,  a  considerable  part  of  the  organ  having  apparently  been  de- 
stroyed, and  on  the  other  with  a  small  opening  in  the  wall  of  the  cecum  at  a 
point  about  an  inch  and  a  half  distant  from  and  below  the  base  of  the  appendix. 
The  cavity  of  the  abscess  was  wiped  out  and  the  granulation  tissue  forming 
its  walls  was  removed  with  a  curette.  The  hole  in  the  gut.  was  closed  with 
several  mattress  stitches;  the  appendix  was  amputated  at  its  base,  surrounded 
by  a  purse-string  suture  and  inverted  in  the  intestine. 

The  necessary  manipulations  of  the  cecum  were  prolonged  and  severe.  A 
small  drainage  wick  was  placed  in  contact  with  the  sutured  portion  of  the  gut 
and  the  cavity  of  the  abscess,  and  led  out  through  the  abdominal  wound.  The 
remainder  of  the  wound  was  closed  by  sutures.     The  patient  bore  the  operation 


COMPLICATIONS    FOLLOWING    ABDOMINAL    OPERATIONS        771 

well;  his  temperature  rose  after  forty-eight  hours  to  101.8°  F.  He  vomited 
several  times  on  the  day  following  the  operation,  and,  although  on  the  next 
day  his  temperature  fell  to  99°  F.,  and  remained  at  that  point  for  the  following 
five  days,  his  stomach  continued  irritahle.  His  bowels  moved  freely  upon  the 
third  day ;  the  vomiting  was  greatly  diminished  in  frequency  by  washing  the 
stomach.  The  wound  remained  entirely  clean  except  for  the  discharge  of  a 
small  amount  of  pus  along  the  sinus  created  by  the  drainage  wick.  At  the  end 
of  a  week  his  condition  was  entirely  satisfactory,  but  on  the  eighth  day  the 
vomiting  recurred.  He  had  had  one  or  more  movements  daily  from  the  bowels 
up  to  this  time. 

Although  the  wound  remained  clean,  his  temperature  rose  on  the  tenth  day 
to  101.8°  F.  During  the  ninth  and  tenth  days  following  the  operation  he 
began  to  vomit  more  often,  and  to  complain  of  pain  in  the  stomach  after  taking- 
food  ;  his  bowels  became  difficult  to  move,  and  upon  the  tenth  day  the  vomited 
material  changed  in  character,  became  of  a  dark-brown  color,  and  had  a  dis- 
agreeable odor.  He  also  suffered  from  severe  abdominal  pains,  and  his  pulse 
showed  signs  of  failing  strength.  Upon  the  eleventh  day  he  did  not  vomit ; 
his  bowels  moved  once ;  but  upon  the  following  day  the  vomiting  and  abdominal 
pains  recurred.  LTpon  the  fourteenth  day  this  condition  was  more  serious,  the 
vomiting  and  pain  continued,  and  the  vomited  material  was  of  a  decided  fecal 
character.  Numerous  high  enemata  brought  away  only  small  amounts  of  fluid 
feces  mixed  with  mucus  and  blood.  He  began  to  grow  very  weak  and  to  suffer 
from  abdominal  distention,  with  severe  abdominal  pains.  His  pulse  became 
very  rapid  and  feeble  in  spite  of  powerful  stimulations.  On  the  morning  of 
the  fifteenth  day  the  signs  of  acute  intestinal  obstruction  were  unmistakable. 
His  eyes  were  sunken,  his  extremities  cold,  his  abdomen  distended ;  he  vom- 
ited frequently,  and  the  vomited  materials  were  distinctly  stercoraceous.  The 
bowels  could  not  be  made  to  move.  Accordingly,  upon  the  fifteenth  day  he  was 
etherized,  and  a  median  abdominal  incision  was  made,  with  its  center  opposite 
the  umbilicus ;  the  peritoneum  was  clean,  but  coils  of  distended  and  congested 
small  intestine  presented  in  the  wound.  These  were  pushed  toward  the  left, 
when  other  coils  of  small  intestine  were  seen  in  a  collapsed  state,  which,  being 
followed,  led  to  the  right  side  of  the  abdomen  in  the  region  of  the  ascending 
colon.  The  ascending  colon  and  two  coils  of  small  intestine  were  found  agglu- 
tinated into  a  solid  mass.  The  coils  above  this  mass  were  distended,  those 
below  were  collapsed.  Upon  further  examination  a  broad,  fibrous  band  was 
seen  passing  from  the  ascending  colon  toward  the  left ;  behind  it  was  the  outer- 
most coil  of  small  intestine.  Its  caliber  was  completely  shut  off  by  the  pressure 
of  this  band.  The  inner  coil  did  not  appear  to  be  completely  obstructed,  and 
the  band  extended  across  its  front  to  be  attached  upon  the  farther  side  to  its 
mesentery.  The  band  was  divided  and,  as  far  as  possible,  cut  away  with  the 
scissors,  when  the  collapsed  coils  immediately  filled  from  above.  The  two 
coils  of  small  intestine,  however,  were  found  firmly  adherent  to  one  another 
over  an  area  represented  by  nearly  half  their  surfaces  for  a  distance  of  about 


772  INJURIES    OF    SPECIAL   ABDOMINAL    ORGANS 

three  inches.  They  were  separated  with  difficulty.  The  bleeding  during  the 
manipulations  was  considerable,  and  the  patient's  condition  indicating  an 
alarming  collapse,  he  received  a  hot  saline  intravenous  infusion  of  2,000  c.c. 

Temporary  pressure  was  applied  to  these  bleeding  surfaces  by  means  of 
gauze  pads,  and  the  pelvis  was  explored  for  other  possible  causes  of  obstruction. 
Numerous  bands  and  broad  adhesions  were  also  found  between  the  coils  of 
small  intestines  situated  in  the  pelvis ;  although  not  apparently  causing  trouble, 
the  bands  were  cut  away.  The  broad  adhesions  were  let  alone.  The  bleeding 
here  was  checked  by  temporary  packing.  The  coils  of  small  intestines  which 
had  been  obstructed  were  moved  as  far  as  possible  toward  the  left  side  of  the 
abdomen.  The  site  of  the  operation  was  thoroughly  washed  with  hot  salt  solu- 
tion and  wiped  dry. 

The  abdominal  wound  was  closed  with  sutures  except  at  its  lower  part, 
where  an  opening  was  left  for  two  strands  of  gauze  leading  from  the  bottom 
of  the  pelvis  and  from  the  inner  side  of  the  ascending  colon,  where  it  had  been 
adherent  to  the  small  intestines.  Although  very  weak,  the  patient  responded 
to  the  most  active  stimulation,  and  upon  the  following  day  a  small  movement 
from  the  bowels  occurred  as  the  result  of  an  enema.  His  temperature  rose  to 
102.4°  F.  at  the  end  of  forty-eight  hours.  He  was  fed  chiefly  per  rectum  for 
two  days,  after  which,  the  vomiting  having  subsided,  he  was  given  liquid  nour- 
ishment by  the  mouth.  At  the  end  of  forty-eight  hours  an  abundant  movement 
of  the  bowels  occurred,  after  which  movements  occurred  regularly  without 
trouble.  The  abdominal  wound  remained  clean,  and  the  packing  was  removed 
at  the  end  of  the  fifth  day  and  replaced  by  a  much  smaller  quantity.  His 
abdominal  wound  healed  for  the  most  part  per  primam,  and  he  has  now  almost 
a  linear  scar.  His  convalescence  was  slow  but  uninterrupted.  I  saw  him 
seven  years  later.     He  had  remained  quite  well. 


MDEX   OF  AUTHOES 


Abbe,  567,  755. 
Albers,  355. 
Albert,   140. 
Andre,  307. 
Arning,  326. 
Aurran,  645. 
Ayer,  313,  430. 

Babes,  129. 

Bailey,  429. 

Bandi,  305. 

Barringer,   654. 

Barterelli,  131. 

Barwell,  558. 

Beck,  381. 

Beer,  308. 

Benda,  170. 

Bergeat,  592. 

Bergmann,   85,   429,   435,  466. 

BlERFREUND,    51. 
BlGNAMI,    106. 

Billroth,  85,  153,  221,  259,  685. 
Bolton,  160,  230,  268,  652,  737. 
Bouley,   127. 
Brewer,  97. 
Brown,  294. 
Bruns,  33,  179,  238. 
Buschke,  307. 

Cabot,    124. 

Caldwell,  344. 

Calmette,   17,  20,  21. 

Ciiipault,  422,  425,  429. 

Coleman,   144. 

Coley,  223. 

Conner,  249. 

Coolidge,   582. 

Cordua,   143. 

Cornil,   106,  221. 

Crisp,  558. 

Cunningham,  17. 

Cunningham,  R.  H.,  343. 

Cushing,  417,  418,  419,  420. 


David,  645. 

Davidson,  360,  371,  372. 
Delafield,  750. 
Dennis,  223,  234. 
Dietrich,  242. 
Doederlein,  71. 
Donath,  349,  350. 
Dowd,  158,  213,  406,  481. 
Downes,  569,  606,  607. 
Dreyer,  307. 
Ducray,  314. 
Dunham,  597. 

Ehrlich,  100,  107,   10S,  111,  112,  148. 
Einhorn,   106. 
Eiselberg,  763. 
Eliot,  233,  452. 
Elsholz,  108,  109. 
Epstein,  121,  243. 
Erb,  428. 

Ernst,  66,  135,  144.   147,  202. 
Ewing,    51,    52,    53,    90.    104.    10S.    109.    124. 
137,   140,   144,  242,  .252,  303,  580. 

Favre,  307. 
Fayrer,  14. 
Fisher,  242,  243.  307. 
Flexner,  17,  19,  95. 
Flugel,  307. 
Fordyce,  320,  322. 
fournier,  313. 
Fox.    319. 
Fraenkel,   727. 

Gabbets,  149. 
Gibson,  227. 
Giemsa,  305. 
Goldiiorn,  305. 

GORHAM,    130. 

Gowers,  429, 
Gray,  596. 
Gross,  683. 

773 


774 


INDEX    OF    AUTHORS 


Gbuber,  506. 

Gbubleb,  129. 

Geunmach,  346,  347,  351,  380. 

GULLAND,    106. 
GUNDELACH,    347. 
GUNDOBIN,     108. 
GUELET,    291. 

Guyon,  696. 

Haage,  179. 

Hackee,  599,  611,  613,  614. 

Hall,  34. 

Halsted,  479,  480,  685,  686,  688. 

Haetley,   153,   154,   168,   172,   200,  283,   398, 

425,   563,   642,   666,  686. 
Hayem,  54,  120. 
Heidenhain,   106. 
Hellee,  238. 
Henle,  670. 
Heez,  50. 
Hessleb,  118. 
Hitzrot,  208,  232,  400. 
hochenegg,  648. 
Hodenpyl,  754. 

Hoffmann,  303,  304,  305,  307,  308. 
Hotchkiss,  241,  399,  557. 
Hunt,  307. 
Huntington,  631. 
Husemann,  21. 

Jackson,   196. 

Jaksch,  106. 

Jennoe,  112. 

Johnson,  6,  7,  11,  24,  33,  35,  36,  38,  39,  40, 
41,  43,  44,  45,  58,  67,  68,  77,  78,  90,  103, 
134,  137,  140,  155,  157,  158,  163,  170,  183, 
186,  190,  191,  206,  209,  219,  223,  224,  228, 
238,  243,  244,  253,  254,  255,  258,  259,  265, 
267,  275,  278,  284,  285,  290,  294,  312,  313, 
315,  323,  324,  332,  336,  344,  347,  349,  350, 
351,  352,  356,  358,  359,  362,  365,  366,  370, 
375,  376,  377,  378,  379,  380,  381,  382,  390, 
397,  409,  415,  416,  429,  434,  447,  451,  457, 
458,  459,  462,  468,  469,  471,  475,  485,  486, 
490,  499,  520,  523,  524,  526,  527,  530,  537, 
540,  541,  542,  543,  547,  549,  553,  556,  557, 
565,  566,  568,  571,  573,  579,  584,  585,  601, 
604,  606,  607,  609,  614,  627,  634,  641,  645, 
647,  650,  652,  653,  654,  672,  673,  675,  676, 
677,  678,  679,  681,  685,  688,  695,  697,  699, 
700.  703,  713,  716,  719,  720,  721,  726,  728, 
73],  732,  734,  737,  739,  740,  743,  746,  749, 
752.  753,  754,  755,  757,  759,  760,  763,  768, 
769,  770,  772. 

Jolly,  106,  111. 


Kelly,  582,  587,  594. 

Keyes,  305. 

Killian,  582. 

Kiestein,  582. 

Klebs,  238. 

Klein,  63,  109. 

Koch,  148. 

Kochee,  21,  266,  763. 

Konig,  670,  677. 

Keaus,  307. 

Keonlein,  422,  424,  432,  433. 

Kummel,  466. 

KiisTEB,  249. 

Lamb,  17,  20. 

Lebanc,   127. 

Lennandee,  727. 

Leonabd,  346. 

Levaditi,  106,  305,  307,  308. 

LlEBEEMEISTER,     118. 

Limbeck,  50,  57,  10S. 
Loison,  642. 
Lcsvit,   107. 

LUBBERT,    61. 

Ludwig,  522. 
Luke,  221. 
Lyon,  56. 

MacEwen,  118. 

Madelung,  573,  663. 

Malgaigne,  292. 

Manasse,  249. 

Markoe,   240,  260. 

McBurney,  164,  165,  166,  170,  195,  210,  211, 
219,  228,  236,  237,  244,  245,  246,  247,  248, 
250,  251,  257,  258,  259,  261,  263,  325,  401, 
416,  445,  446,  448,  454,  456,  458,  464,  47S, 
524,  525,  532,  567,  573,  575,  576,  577,  623, 
684,  687,  688,  699,  748. 

Mendel,  106. 

Mensser,  252. 

Merkel,   544,   632,   637,   638,   668. 

Mikulicz,  51,  523,  599,  614,  617,  753. 

Mintz,  677. 

Mitchell,  17,  19,  20. 

Monakow,  419. 

Monks,  760. 

Moeeis,  755. 

Moeton,  210. 

MUELLEB,    109. 

Muib,  63,   135,   144. 
MtiLLEE,  683. 
Mulzee,  307. 
Munde,  266. 


INDEX    OF    AUTHORS 


Ub 


Murray,    184,   185,  206,  229,   243,  263,   264, 
402,  454,  552,  554,  682,  689,  696. 

Nasse,  106. 

Negri,  128,  129,  130,  131. 
Neisser,  306. 
Nelis,  128,  129. 
Nicholas,  307. 
Nielsen,  149. 
noggerath,  307. 
Noguchi,  17,  19. 
Noniewitch,    144. 
Norris,   196. 
Now,  308. 

Oppenheim,  307. 
Osler,  128,  655. 

Paget,  672,  685. 
Paltauf,  151. 
Parrot,    193. 
Pasteur,  65,  127,  202. 
Paul,  420. 
Peabody,  242. 
Pel,  243. 
Petresco,  307. 
Petruschky,  62. 
Piffard,  322. 

PlROGOFF,    42S. 

Politzer,  506,  509,  510,  511. 
Pollak,   509,  510. 
Powers,  68. 
Prautschoff,  307. 
Prowazek,  304. 
Pruddex,  750. 
purkinje,  131. 
Putnam,  602,  603. 

QUERAIN,    21. 

Rand,  760. 
Ranvier,  221. 
Ravenel,  128. 
Reichel,   172. 
Reinert,  56,  121. 
Richards,  307. 
Rieder,  108,  109,  112. 

RlEHL,    151. 
RlNNE,    509. 

Ritchie,  63,  135,  144. 
Roberts,  97,  98. 
Robinson,  172. 
Roloff,  677. 
Roscher,  307. 


Rose,  639. 
Rosexbach,  143. 
Rumpel,  617. 

Sachs,  307. 

Sasse,   677. 

Schaudinn,  303,  304,  305,  307. 

Sciiede,  219. 

Schimmelbusch,  677,   681. 

Scholtz,  307. 

Schultze,    106,   107. 

schwartze,  508. 

Semox,   593. 

Sendziak,  592. 

Senn,  180. 

Sherrington,  417,  418. 

SlEBERT,    307. 
SlMONELLI,    305. 
SOBERNHEIM,    307. 
SONDERN,    103. 

Stahelin,  307. 

Stanley,  21. 

Starr,  429,  436,  438,  439. 

Stimson,    167,   240,   275,  289,  292,  295,   301, 

392,  405,  409,  411,  441,  561,  628,  645,  647, 

760. 
Stuard,  343. 
Sutton,  248,  249,  266. 
Sweet,  371,  373. 

Thatcher,  90. 

Thoma,  56. 

Tietze,  677. 

Tillmanns,  238,  249,  269,  428. 

Toepel,  307. 

Toisson,  54. 

Tomasczewski,  307. 

Traube,  662. 

Trosseau,   126,  570. 

Turck,  106. 

Unna,  314. 

Valenti,  129. 

Valsalva,  506,  512. 

Van  Gehuchten,  128,  129. 

VlERORDT,    726. 

Virchow,   106,  221,  264. 
Volkmann,   174,   249,  301,  302. 
Volpino,   130. 

Walsh,  371. 
Walton,  420. 
Weber,  509,  512. 


776 


INDEX    OF   AUTHORS 


Wehnelt,  341,  344,  380. 

Weiss,  214. 

Welch,  67,  68,  69,  70,  71,  95. 

Wolfler,  573,  576. 

Woolsey,  419. 

Weight,   141. 

wunderlich,  118. 


Youatt,    145. 

Zappert,  109. 
Zenker,  617. 
Ziegler,  238. 

ZlEHL,    149. 
ZUCKERKANDL,    565. 


IJTOEX   OF   SUBJECTS 


Abdomen,  gunshot  wounds  of,  735,  737. 
stab  wounds  of,  734,  735. 
wounds  of  penetrating,  732. 

symptoms  and  diagnosis  of,  733. 
Abdominal  actinomycosis,   140. 
contents,  732. 

general  and  special  data  of,  730. 
subcutaneous  injuries  of,  739. 

groups  of  symptoms  observed  in,  739. 
Abdominal  muscles,  rupture  of,  093. 
Abdominal    operations,    complications    follow- 
ing, diagnosis  of,  702. 

hemorrhage   from   alimentary  canal,   703. 

infection  of  external  wound,  705. 

intestinal  obstruction,  708. 

localized,  707. 

peritonitis,   700. 

pneumonia,  707. 

pulse  in,  705. 

retention  of  urine,  704. 

shock,   702. 

symptoms  referable  to  intestine,  704. 

temperature  in,  704. 

thrombosis  and  embolism,  707. 
Abdominal  wall,  actinomycosis  of,  098. 
contused  wounds  of,  094. 
contusions  of,  092. 

shock  after,  092. 
diseases  of,  095. 
foreign  tjodies  in,  094. 
gunshot  wounds  of,  094. 
inflammations  of,  095. 
inflammations  of,  deep-seated,  095. 
injuries  of,  092. 

introduction  of  aspirating   needle   and   tro- 
car through,  715. 
lacerated  wounds  of,  094. 
tumors  of,  dermoid,  098. 

echinococcus,  700. 

epithelial  growths,   700. 

fibroma,   G9S. 

lipoma,    700. 

sarcoma,  099. 
wounds  of,  093. 


Abducens  nerve,  paralysis  of,  428. 
Abnormal  mobility  in  fractures,  280. 

method  of  examination  of,  281. 
Abscess,  acute,  fluctuation  in,  82. 

heat  in,  80. 

pain  in,  79. 

physical  signs  and  symptoms  of,  79. 

redness  in,  80. 

special  symptoms  of,  83. 

swelling  in,  81. 

tenderness  in,  83. 
axillary,  95. 
cold,  162. 

of  joints,  164. 
diagnosis  of,  79. 
in  soft  parts  of  ear,  517. 
intramammary,  075. 
of  brain,  433. 

chronic,   diagnosis  of,  434. 

differential   diagnosis   of,  436. 

following  middle-ear  disease,  435. 

latent,  diagnosis  of,   434. 

secondary  to  infectious  processes  of  nose 
and  the  frontal  sinus,  436. 

symptoms  of,  434. 
of  lung,  659. 

physical  signs  of,  600. 
of  submucous  tissues  of  nasal  fossae,  468. 
peritonsillar,  493. 
retromammary,  675. 
retropharyngeal,  494. 

signs  and  symptoms  of,  550. 
secondary,  in  liver,  99. 
subphrenic,  in  localized   peritonitis,  724. 
symptoms  and  diagnosis  of,  724. 

physical  signs  of,  724. 
Abscesses    arising    in    deep    lymph    nodes    of 
neck,  548. 
at  angle  of  jaw,  548. 
in  cerebellum.  435. 
in  supraclavicular  region,  549. 
of  breast,  chronic.  676. 
of  retropharyngeal  space,  chronic,  551. 
of  submental  lymph  nodes,  548. 
777 


778 


IKDEX    OF    SUBJECTS 


Abscesses  of  thoracic  wall,  648. 
cold,    649. 
peripleuritic,  649. 
subcutaneous,  of  hairy  scalp,  395. 
Accessory  thyroid  glands,  499,  573. 
Accumulated  cerumen  in  external  ear,  504. 
Achondroplasia,  193. 
Acinous  cancer  of  breast,  6S5. 
Acinous  carcinoma    (Billroth),  259. 
Acne  rosacea  of  face,  455. 
Acoustic  nerve,  injuries  of,  42S. 
Acromegaly,  197. 

Actinomycosis,  abdominal,  140,  698. 
differential  diagnosis  of,  141. 
identification  by  cultures  of  (Wright),  141. 
of  breast,  679. 

of  central  tissues  of  jaw,  39. 
of  face.     See  Actinomycosis. 

clinical  diagnosis  of,  139. 
of  jaws,  475. 
of  lung,  663. 
of  neck.     See  Actinomycosis,  551. 

clinical  diagnosis  of,   139. 
of  pleura,  659. 
of  thoracic  wall,  649. 
of  tongue,  486. 
of  wounds,  137. 

avenues  of  infection  of,  13S. 
clinical  diagnosis  of,  139. 
essential  lesion  of,  138. 
of  the  lung,  140. 
upon  the  tongue,  140. 
Acuminate  warts,  253. 
Acute  articular  rheumatism,  182. 
Acute     catarrhal     inflammation     of     frontal 

sinus,  443. 
Acute  emphysematous  gangrene  produced  by 

bacillus  aerogenes  capsulatus,   95. 
Acute  exudative  lesions  of  joints,  diagnosis  of, 

174. 
Acute  gastro-enteritis,  716. 
Acute  inflammation  of  breast,  673. 
diagnosis  of,  675. 
symptoms  of,  674. 
Acute  inflammation  of  cranial  bones,  412. 
Acute  inflammation   of  nasal   membrane,  467. 
.Acute  inflammation  of  periosteum,  412. 
Acute  inflammation  of  thyroid  glands,  571. 
Acute    inflammatory    affections    of    pharynx, 
491. 
differential  diagnosis  of,  493. 
Acute  inflammatory  affections  of  tonsils,  491. 

differentia]   diagnosis  of,  493. 
Acute  mastitis,  673. 
diagnosis  of,  675. 


Acute  mastitis,  symptoms  of,  574. 
Acute  nonsuppurative  mastitis,  676. 
Acute  osteomyelitis,   179. 

case  of,  181. 

differential  diagnosis  of,  182. 

general  symptoms  of,  181. 

local  symptoms  of,  180. 

of  clavicle,  650. 

of  cranial  bones,  412. 

of  ribs,  650. 

of  sternum,  650. 
Acute  phlebitis,  335. 
Acute     phlegmonous     inflammation     of     soft 

parts  of  thorax,  648. 
Acute    suppuration  in  prevesical   space,  signs 

and  symptoms  of,  696. 
Acute  suppurative  inflammation  of  the  middle 

ear,   512. 
Acute  suppurative  inflammation  of  pia  mater, 

432. 
Acute  suppurative  inflammation  of  submaxil- 
lary gland,  522. 
Acute  suppurative  inflammatory  processes  of 

neck,  547. 
Acute  suppurative  mastitis,  diagnosis  of,  675. 

symptoms  of,  674. 
Acute  suppurative  mediastinitis,  665. 

pressure  symptoms  in,  665. 
Acute  suppurative  periostitis  of  jaws,  474. 
Acute  synovitis  of  jaws,  482. 
Adenocarcinoma,  259. 

of  breast,  686. 
Adenoid  tumors,  497. 
Adenoma.  254. 

of  salivary  glands,  527. 

of  sweat  glands  of  face,  457. 
Air  passages,  foreign  bodies  in,  583. 

diagnosis  of,  586. 
Alimentary   canal,   hemorrhage  following   ab- 
dominal operations  from,  763. 

injury  to,  signs  and  symptoms  of,  735. 

special  groups  of  symptoms  in  septic  infec- 
tions of,  101. 
Alimentary  tract,  ruptures  of.  740. 
Alveolar  border,  fractures  of,  471. 
Anastomosis,  aneurism  by,  236, 
Anatomical    and    physiological    considerations 

of  breast   (after  Merkel),  668. 
Anatomical    observations  in   open   wounds  of 
the  scalp.  389. 

in  subcutaneous  wounds  of  scalp,  386. 
Anatomical   tubercle.   151. 
Anemia  (Ewing),  252. 
Aneurism,   329. 

artcrio-venous,  329. 


IXDKX    OF    SUBJECTS 


779 


Aneurism   by  anastomosis,  236. 

circumscribed,  330. 

cirsoid,  236. 

course  of,  331. 

diagnosis  of,  332. 

diffuse,  329. 

dissecting,  329. 

of  aorta,  667. 

of  arteries  of  skull,  415. 

sacculated,  329. 

symptoms  of,   330. 
physical,  330. 

thrill  of,  333. 

traumatic,  10. 
symptoms  of,  10. 

varicose,  11,  329,  334. 
Aneurismal  sac,  pyogenic  infection  of,  331. 
Aneurismal  varix,   11,  333,  329. 
Aneurisms  of  neck,  558. 

arterio-venous,   between  common  carotid  ar- 
tery and   internal  jugular   vein,  560. 

of  common  carotid  artery,  558. 

of  external  carotid  artery,  558. 

of  innominate  artery,  558. 

of  internal  carotid  artery,  558. 

of  subclavian  artery,  559. 

of  vertebral  artery,  560. 
Aneurisms  of  scalp,  399. 
Aneurisma   racemosum,  236. 
Angina  Ludovici,  522. 
Angioma,  235. 

arteriole  racemosum,  236. 

cavernous,  235. 
of  tongue,   487. 

of  neck,  565. 

cavernosum,  565. 

of  salivary  glands,  524. 

of  thorax,  congenital  cavernous,  652. 

of  tongue,  487. 

simplex,  235. 
of  neck,  565. 
of  scalp,  402. 
of  tongue,  487. 
Angiomata  of  face,  455. 

of  scalp.    See  Cirsoid  Aneurism. 
Angiosarcoma,  plexiform,  249. 
Angular  displacement,  293. 
Ankylosis,   176. 

etiology  of,  177. 
Anorexia  in  diffuse  purulent  peritonitis,  711. 
Anterior  rhinoscopy,  465. 
Anthrax  of  face,  450. 

of  scalp,  396. 

of  wounds,  135. 
definition  of,  135. 


Anthrax  of  wounds,  diagnosis  of,   137. 
occurrence  of,   136. 
period  of  incubation  of,  136. 
sources  of  infection  of,  136. 
surgical  bacteriology  of   (Ernst),  135. 
synonyms  of,  135. 
variations  in  the  course  of,  137. 
Antrum  of  Highmore,  diseases  of,  476. 

empyema  of,  476. 

hydrops  of,  476. 

tumors  of,   477. 
Anus,  artificial,  758. 
Anus  preternaturalis,  758. 
Aorta,  aneurism  of,  667. 
Apophysis,  separation  of,  275. 
Appendicitis,  gangrenous,  99. 

case  of,  100. 
Areola,  atheromatous  cysts  of,  673. 

diseases  of,  672. 

eczema  of,  672. 

syphilis  of,  672. 
Arsenious  acid,  eschars  produced  by,  750. 
Arterial  hematoma,  10,  329. 

symptoms  of,  10. 
Arterial   supply  of  scalp,   389. 
Arteries,  acute  inflammation  of,  334. 

chronic  inflammation  of,  335. 

hemorrhage  from  wounds  of,  47. 

in  cranial  cavity,  427. 

intercostal,  wounds  of,  630. 

of  skull,  aneurism  of,  415. 
Arterio-venous  aneurism,  329,  332. 

diagnostic  signs  of,  334. 

forms  of,  333. 

of    neck,    between    common    carotid   artery 
and  internal  jugular  vein,  560. 

of  orbit,  460. 

signs  and  symptoms  of,  333. 
Artery,  internal  carotid,  injury  of,  427. 

internal  mammary,  wounds  of,  629. 

middle   meningeal,    hemorrhage    in    circum- 
scribed  fractures  of  skull   from,  408. 
Arthralgia,  syphilitic,  171. 
Arthritis  deformans,  167. 

syphilitic,  171. 

temporo-maxillary  articulation  of,  4s2. 

tubercular,   159. 
Artificial  anus,  758. 
Artillery,  wounds  produced  by,  46. 
effects  of  canister  shell,  47. 
effects  of  shrapnel  shell,  46. 
Aseptic  healing  of  gunshot  wounds,  29. 
Aseptic  peritonitis,  731. 
Aseptic  wound  fever,  85. 

symptoms  of,  85. 


780 


IXDEX    OF    SUBJECTS 


Aspirating    needle,    introduction    of,    through 
abdominal  wall,   715. 

use  of,  S3. 

in  diagnosis  of  acute  exudative  lesions  of 
joints,.  174. 
Aspiration  of  air  into  veins.  48. 
Associated  lesions  of  heruatoruata,  387. 
Atheromatous  cyst  of  scalp,  400. 

subcutaneous.  564. 
Atheromatous  cysts  of  nipple,  673. 
Atheromatous  degeneration,  335. 
Atresia  of  external  ear,  502. 
Atrophic  rhinitis.   467. 
Atrophy,  acquired,  of  tongue.  4^4. 

in  tuberculous  osteomyelitis,  189. 

of  skull,  414. 
Auditory  cortex  of  brain.  420. 
Auscultation  in  diseases  of  pleura,  655. 
Axillary  abscess.  95. 

Bacteria,  causing  peritonitis.   706. 
in  surgical  infections,  60. 

Bacillus   aerogenes   eapsulatus,   95. 

Bacillus  coli  communis,  63. 

Diplococcus  pneumoniae,  64. 

Gonococcus.  64. 

Micrococcus  tetragenus.  characters  of,  62. 

Staphylococcus    cereus    flavus,   characters 
of,  61. 

Staphylococcus    pyogenes    albus,    charac- 
ters of,  61. 

Staphylococcus  pyogenes  aureus,,   charac- 
ters of,  60. 

Staphylococcus  pyogenes  eitreus,  charac- 
ters of,  61. 

Streptococcus  pyogenes,  characters  of,  61. 

Streptococci,  varieties  of,  02. 
occurrence  of,  in  conjunctiva,  69. 

in  endometrium,  71. 

in  milk  of  breast,.  71. 

in  mouth.  69. 

in  normal  cervix.  71. 

in  throat.  69. 

in  tonsils,  69. 

in  vagina.  71. 
of  biliary  passages   (Welch).  70. 
of  intestine.  70. 
of  stomach    (Welch  i.    70. 
pathological     characters     of,    Bacillus     coli 
communis,  07. 

Bacillus  pyocyaneus,  67. 

Gonococcus,  68. 

Micrococcus  tetragenus,  68. 

Staphylococci,  07. 

Streptococcus,  67. 


Bacteria,  portals  of  entry  of,  in  pyogenic  in- 
fections,  71. 

pus-producing,  varieties   of  diseases   caused 
by,  60. 

resistance  of  organism  to.  72. 

sources  of,  in  pyogenic  infections,  71. 

toxic  effects  of,  72. 
Bacillus    tuberculosis,    laboratory    identifica- 
tion of,  147. 
Basal  ganglia,  421. 
Basedow's  disease,  569. 
Bedsore,  213. 
Bent  bone  fractures,  275. 
Bilateral  disturbance  of  knee-joints,  172. 
Biliary  passages,  bacteria  of    (Welch),   70. 
Birdshot  wounds  of  scalp,  391. 
Birth-mark,  235. 
Bites  of  insects,  22. 

characters  of,  23. 
Black  powder,  effects  of.  upon  skin,  34. 
fired  at  short  range,  33. 

effects  upon  linen,  39. 
Bladder,  villous  tumor  of,  254. 
Bleeding,   capillary,  49. 

intra-abdominal,  symptoms  of,  735. 

parenchymatous,  49. 
Blood   changes   after  hemorrhage   of  wounds, 

50    (Ewing). 
Blood,  counting  red  cells  in,  55. 

estimation  of  red  cells  in,  52  (Ewing). 

histological  examination  of   (Ewing),  109. 

in  septic  processes,  103. 
Blood  cultures  in  septic  diseases,  89. 

method  of  procedure  in  making  of,  90. 
Blood  cyst  of  neck,  564. 

of  scalp,  403. 
Blood  supply  of  breast,  670. 
Blood-vessels,  inflammation  of,  334. 

injuries  to,  288,  296. 

of  brain,  injuries  of,  426. 

of  neck,  in  general,  wounds  of,  537. 

of  neck,  particular,  wounds  of,  538. 
Bone,  contusion  of,  result  in  periostitis  of,  187. 

dislocated,  fracture  of,  296. 

echinococcus  cyst  of,  269. 

lesions  of  hereditary  syphilis  of  bone,  192. 

malar,  fractures  of,  471. 

syphilis  of,  1S9. 

tuberculosis  of,  157. 
diagnosis  of,  164. 
differential  diagnosis  of.  165. 
Bones,  cranial,  acute  inflammation  of,  412. 
acute  osteomyelitis  of,  412. 
syphilis  of,  413. 
tumors  of,  415. 


INDEX    OF    SUBJECTS 


781 


Bones,  syphilis  of,  326. 
Bony  tumors,  233. 

Bowel,  distention  of,  in  diffuse  purulent  peri- 
tonitis, 714. 

paralysis  of,  in  diffuse  purulent  peritonitis, 
714. 
Brain,  abscess  of,  433. 

differential   diagnosis  of,  43G. 

auditory  cortex  of,  420. 

bullets  in,  429. 

chronic  abscess  of,  diagnosis  of,  434. 

compression  of,  42G. 

concussion  of,  424. 

contusion  of,  428. 
symptoms  of,  429. 

foreign  bodies  in,  429. 

general  cortex  and  frontal  lobes  of,  420. 

injuries  of,  424. 

laceration  of,  428. 

laceration  of,  symptoms  of,  429. 

latent  abscess  of,  diagnosis  of,  434. 

motor  area  of  cortex  of,  418. 

prolapse  through  wound  of,  430. 

sarcoma,  437. 

symptoms  of,  general,  438. 
local,  438. 

speech  areas  in,  420. 

tuberculous  disease  of,  437. 

tumors  of,  43G. 
gumma,  437. 

visual  cortex  of,  420. 

wounds  of,  428. 

wounds  of,  symptoms  of,  429. 
Breast,  actinomycosis  of,  679. 

acute  inflammation  of,  673. 
diagnosis  of,  675. 
symptoms  of,  674. 

anatomical     and     physiological     considera- 
tions of  (after  Merkel),  668. 

blood  supply  of,  670. 

caked,  676. 

chronic  abscesses  of,  676. 

congenital  anomalies  of  breast,  671. 

diffuse  miliary  tuberculosis  of,  679. 

diseases  of,  672. 

hypertrophy  of,  680. 

inflammations  of,  673. 

injuries  of,  671. 

lymphatics  of,  670. 

milk  of,  occurrence  of  bacteria  in,  71. 

nerves  of,  670. 

neuralgia  of,  680. 

tuberculosis  of,  diagnosis  of,  678. 

tubular  cancer  of,  685. 

tumors  of,  681. 


Breast,  tumors  of,  benign,  fibro-adenoma,  681. 
lipoma,  683. 
pure  myxoma,  683. 
eystosarcoma,  682. 
general  considerations,   statistics  of,   681. 

adenocarcinoma,  686. 
malignant,  acinous  cancer,  685. 

cancer,  clinical  course  and  diagnosis  of, 

686. 
carcinoma,  6S4. 
contraindications  to  operation,  690. 

practical  suggestions,  690. 
carcinoma  simplex,  685. 
colloid  cancer,  686. 
sarcoma,  683. 

scirrhous  carcinoma  of,  686. 
tumors  of  male,  690. 
Bronchiectasis,  662. 
symptoms  of,  662. 
Bronchocele,  572. 

differential  diagnosis  of,  575. 
laryngoscopic  examination  of,  576. 
symptoms  of,  574. 
Bullet  wound  of  stomach,  745. 
of  small  intestine,  745. 
topography  of,  29. 
Bullets,   effects   of  lodgment  of,   diagnosis  of, 
31. 
high-powered,  straight  path  of,  30. 
in  brain,  429. 

soft-nosed,  diagnosis  of,  wounds  of,  33. 
effects  of,  32. 
Burning  of  face,  448. 
Burns  of  esophagus,  543. 

of  first  degree,  symptoms  of,  211. 
of  larynx,  583. 
of  neck,  536. 
of  second  degree,  211. 
of  third  degree,  211. 
of  trachea,  583. 
Bursa:,  268. 

tuberculosis  of,  156. 

Cachexia  strumipriva,  570. 
Caked  breast,  676. 
Callus,  weakness  of,  290. 
Cancer,  256. 

glandular,  259. 

of  breast,   clinical  course  and   diagnosis   of, 
686. 

of  the  tongue,  488. 
diagnosis  of,  490. 
Cancroid,  257. 
Canerum  oris,  215. 
Capillary  bleeding,  49. 


782 


INDEX    OF    SUBJECTS 


Caput  obstipum,  531. 

Caput  suecedaneum,  387. 

Carbolic  acid,  eschars  produced  by,  750. 

Carbuncle,  74. 

constitutional  symptoms  of,  397. 

of  face,  449. 

of  scalp,  397. 
Carcinoma,  255. 

acinous  (Billroth),  259. 

cylinder-celled,  259. 

degenerative  changes  in,  256. 

gelatinosum,  261. 

medullary,  261. 

of  breast,  684. 
contraindications  to  operation  upon,  690. 
practical  suggestions  on,  690. 

of  jaws,  477. 

of  larynx,  500,  592. 

of  lower  part  of  pharynx,  499. 

of  lung,  663. 

of  neck,  568. 

of  salivary  glands,  527. 
soft  cellular  form  of,  528. 

of  scalp,  402. 

of  thoracic  wall,  654. 

of  thyroid  gland,  578. 

of  umbilicus,  704. 

scirrhus,  261. 

simplex,  260. 
of  breast,  685. 
Carotid  artery  of  neck,  common  aneurisms  of, 
558. 

internal,  aneurisms  of,  558. 

external,  aneurisms  of,  558. 
Caseation  of  gland  tissue  of  neck,  555. 
Catarrhal  inflammation  of  mucous  membrane 
of  mouth,  483. 

of  esophagus,  acute,  611. 
chronic,  611. 
Catarrhal  stomatitis,  483. 
Catarrhal  tonsilitis,  492. 
Catheterization  of  Eustachian  tube,  510. 

first  method  of,  510. 

second  method  of,  510. 
Caustic  alkalies,  eschars  produced  by,  750. 
Caustics,  symptoms  produced   by  swallowing, 

750. 
Cauterizations  of  esophagus  by  corrosive  liq- 
uids, 611. 
Cavernous   angioma,  235. 

of  tongue,  487. 
Cavernous  lymphangioma,  237. 

of  tongue,  487. 
Cephalhematomata  of  new-born,  388. 
Cephalocele,  440. 


Cephalocele,  diagnosis  of,  442. 

varieties  of,  441. 
Cerebellum,  421. 

abscesses  in,  435. 
Cerebral  localization   (Starr),  417. 
Cerebral  shock,  424. 
Cerebration    in    diffuse    purulent    peritonitis, 

711. 
Cervical    lymph  glands    of   neck,    syphilis  of, 

556. 
Cervical   ribs,  531. 

symptoms  of,  531. 
Cervix,  normal,  occurrence  of  bacteria  in,  71. 
Chancre,  310. 

ecthymatous,  312. 

extra-genital,  313. 

diagnosis  in  early  stages  of,  317. 

hard,  308,  310. 

Hunterian,  308,  310. 

infecting,  310. 

multiplicity  of,  313. 

of  finger,  318. 

of  scalp,  398. 

of  tongue,  485. 

of  vulva,  313. 

soft,  314. 
Chancres,  genital,  in  women,  diagnosis  of,  317. 
Chancres  of  nipple,  317. 

of  tonsil,  317. 
Chancroid,  314. 
Chancroidal  bubo,  315. 
Charcot's  joint,  168. 

Chipault's  method  of  cranio-cerebral  localiza- 
tion, 425. 
Chloroma,  251. 
Cholesteatoma,  267. 
Chondroma,  231. 

of  larynx,  591. 

of  neck,  567. 
Chronic  cystic  mastitis,  677. 

clinical  characters  of,  677. 
Chronic    exudative    peritonitis     (Vierordt,    A. 

Frankel,  Lennander),  727. 
Chronic  interstitial  inflammation  of  submax- 
illary gland,  522. 
Chronic  mastitis,  676. 
Chronic  mediastinitis,  665. 
Chronic  middle-ear  disease,  diagnosis  of,  514. 
Chronic  peritonitis,  727. 

with  production  of  adhesions,  727. 
symptoms  of,  728. 
Chylothorax,  658. 

Cicatricial  strictures  of  esophagus,  613. 
Circumference  of  bone,  displacement  of.  293. 
Circumscribed  aneurism,  330. 


INDEX    OF    SUBJECTS 


783 


Circumscribed  fractures  of  skull,  405. 
Circumscribed  osteomyelitis,  187. 
Circumscribed  phlegmons,  7G. 
Cirsoid  aneurism,  236. 
Claudication,   intermittent,  205. 
Clavicle,  acute  osteomyelitis  of,  650. 
Clavus,  253. 
Cleft  palate,  455,  490. 
Cold  abscess,  162. 

of  joints,   164. 

of  thoracic  wall,  649. 
Colic,  intestinal,  716. 

nephritic,  716. 
Colloid  cancer,  261. 

of  breast,  6S6. 
Colloid  goiter,  577. 
Coma,  411. 

Combinations  of  sapremia  with  septic,  sapro- 
phytic, and  pyogenic  infection,  92. 
Comedones,  457. 
Commotio  cerebri,  424. 
Commotio  thoraeica,  628. 

Complications     following     abdominal     opera- 
tions, diagnosis  of,  762. 

hemorrhage  from  alimentary  canal  in,   763. 

infection  of  external  wound  in,  765. 

intestinal  obstruction,  768. 

peritonitis,  766. 
localized,  767. 

pneumonia,  767. 

pulse  in,  765. 

retention  of  urine,  764. 

shock,  762. 

symptoms  referable  to  intestine,  764. 

temperature   in,   764. 

thrombosis  and  embolism,  767. 
Compression  of  brain,  426. 
Concussion  of  brain,  424. 

of  thorax,  628. 
Condylomata,  flat,  320. 

Congenital  abnormalities  of  external  ear,  446. 
Congenital  anomalies  of  breast,  671. 

of  umbilicus,  701. 

of  urachus,  702. 
Congenital  cavernous  angioma  of  thorax,  652. 
Congenital  cystic  hygroma  of  neck,  563. 
Congenital  cystic  lymphangioma  of  neck,  563. 
Congenital  defects,  cysts  due  to,  265. 

of  esophagus,  602. 

of  external  ear,  501. 

of  face,  445. 
rare,  446. 

of  larynx,  583. 

of  the   neck,   529. 

of  nose,  463. 


Congenital  deformities  of  floor  of  mouth,  484. 

of  muscles  of  thorax,  623. 

of  ribs,  622. 

of  sternum,  622. 

of  thorax,  622. 
acquired,  623. 

of  tongue,  484. 
Congenital  dislocations,  300. 
Congenital  fistulae  of  neck,  529. 

arising    from    imperfect    closure    of    second 
branchial  cleft,  529. 

arising  from  thyreoglossal  duct,  530. 
Congenital  lymphangiectasis,  237. 
Congenital    shortening   of   frenum    of   tongue, 

484. 
Congenital  stricture  of  esophagus,  612. 
Congenitally  fissured  tongue,  484. 
Conjunctiva,  occurrence  of  bacteria  in,  69. 
Contused  wounds,  absence  of  hemorrhage  in,  6. 

examination  of,  6. 

gangrene  in,  7. 

of  abdominal  wall,  694. 

of  scalp,  390. 

shape  of,  7. 
Contusion   in   subcutaneous   wounds  of   scalp, 

signs  of,  386. 
Contusion  of  bone  in  periostitis,  result  of,  187. 
Contusion  of  brain,  428. 

symptoms  of,  429. 
Contusion  of  wall  of  gut,  delayed  perforation 

from,  741. 
Contusions  of  abdominal  wall,  692. 

shock  after,  692. 
Contusions   of  thorax,  625. 
Corrosive  sublimate,  eschars  produced  by,  750. 
Coryza,  acute,  467. 
Costal   cartilages,  fracture  of,  647. 
Cranial  bones,  acute  inflammation  of,  412. 

syphilis  of,  413. 

syphilitic  periostitis  of,  413. 

tumors  of,  415. 
Cranial  cavity,  arteries  in,  427. 
Cranial  nerve  nuclei,  420. 

Cranial  nerves,  affections  of  fifth  and  seventh 
pairs  of,  461. 

injuries  of  fifth  pair  of,  428. 

neuralgia  of  fifth  pair  of.  461. 

within   skull,  injuries  of,  427. 
Cranio-cerebral    topography,  421. 
Crepitus,  283,  299. 
Cretinism  of  thyroid  gland,  570. 
Crushing,  294. 
Cryptogenic  pyemia,  117. 

Cultures,    identification    of   actinomycosis    by 
(Wright),  141. 


784 


INDEX    OF    SUBJECTS 


Cutis  pendula,  453. 
Cyanosis,  regional,  214. 
Cylindroma,  249. 

Cyst,  atheromatous,  of  scalp,  400. 
dermoid,  of  scalp,  400. 
follicular,  264. 
hydatid,  268. 
mucous,  264. 
retention,  265. 
sebaceous,  of  scalp,  400. 
Cystadenoma  mammal,  677. 
Cystic   dilatation   of  salivary   ducts,  523. 
Cystic  lymphangioma,  238. 
of  face,  455. 
of  tongue,  487. 
Cystic  thyroid,  577. 
Cystic  tumors,  202. 
of  tongue,   488. 
ranula,  488. 
Cysticercus  cellulosae,  270. 
Cystosarcoma  of  breast,  682. 
Cystosarcoma-proliferum,  682. 
Cystosarcoma  phyllodes,  682. 
Cysts,  arising  from  thyreoglossal  duct,  563. 
atheromatous,  of  areola,  673. 

of  nipple,  673. 
dermoid,  266. 

due  to  congenital  defects,  265. 
due  to  true  tumor  formation,  263. 
echinococcus,  268,  274. 
of  abdominal  wall,  700. 
of  bone,  209. 
of  neck,  565. 
of  lung,   663. 
of  pleura,  659. 
of  thoracic  wall,  654. 
of  thyroid  gland,  571. 
implantation,  265. 
of  salivary  glands,  524. 
of  second  cleft  of  neck,  563. 
of  Steno"s  duct,  523. 
parasitic,  268. 
retention,  263. 

Deafness,  following  an  injury  to  the  ear,  505. 
Decubitus,  213. 
Deformities  of  thorax,  622. 
Deformity,  278. 

dislocations  by,  302. 
Degenerative  processes  in  careinomata,  256. 
Delirium  tremens,  217,  2S0. 
Depressed    fractures   of   skull,   406. 
Depressed  nipples,  672. 
Depressions  of  bone,  275. 
Dermoid  cysts,  266. 


Dermoid  cysts  of  face,  457. 

of  scalp,  401. 

of  tongue,  488. 
Dermoid  patches,  266. 

Dermoid  tumors  of  abdominal  wall,  698. 
Dermoids,  ovarian,  266. 

sequestration,  266. 

tubulo,  266. 
Destruction,  dislocations  by,   301. 
Diabetic  gangrene,  203. 

varieties  of,  204. 
Diaphragm,  gunshot  wounds  of,  737. 

injuries  of,  643. 
Diastasis,  295. 

Diffuse  inflammation  of  external  ear,  503. 
Diffuse  purulent  peritonitis,  anorexia  in,  711. 

cerebration  in,  711. 

distention  of  bowel  in,  714. 

general  and  local  symptoms  of,  710. 

hiccough   in,   714. 

leucocytosis  in,  711. 

meteorism  in,  714. 

pain  in,  712. 

palpation  in,  712. 

paralysis  of  bowel  in,  714. 

point  pressure  in,  713. 

pulse  in,  710. 

temperature  in,  710. 

tenderness  in,  712. 

tympanites  in,  714. 

urine  in,  711. 

vomiting  in,  713. 
Diffuse  septic  phlegmon,  77. 
Dilatation  of  veins  in  acute  osteomyelitis,  180. 
Dilatations  of  esophagus,  617. 
Diphtheria,  493. 

of  nasal  mucous  membrane,  468. 
Direct  inspection  of  external  ear,  506. 
Direct  longitudinal   separation   of  bones,  294. 
Diseases  caused  by  pus-producing  bacteria,  60. 
Dislocated  bone,  fracture  of,  296. 
Dislocations,  294. 

by  deformity,  302. 

by  destruction,  301. 

by  direct  violence,  295. 

by  distention,  301. 

by  indirect  violence,  296. 

by  muscular  action,  296. 

complete,  295. 

complicated,  295. 

complications  attending,  296. 

compound,  295,  297. 

congenital,  300. 

diagnosis  of,  297. 

differential   diagnosis  of,  298. 


INDEX    OF    SUBJECTS 


785 


Dislocations,  history  of,  298. 

inspection  of,  298. 

loss  of  function  in,  300. 

of  lower  jaw,  472. 

bilateral,  signs  and  symptoms  of,  472. 

of  ribs,  G47. 

from  cartilages,  047. 

of  sternum,  G45. 

of  thorax,  043. 

pain  in,  300. 

palpation  in,  299. 

partial,  295. 

pathological,  301. 

recurrent  or  habitual,  290. 

spontaneous,  301. 

subjective  symptoms  of,  300. 

total,  295. 

traumatic,   295. 

differential    diagnosis  of,   300. 
Displacements,  292. 

angular,  293. 

lateral,  293. 

of  circumference  of  bone,  293. 

of  long  axis  of  bone,  293. 

rotary,  293. 

transverse,  293. 
Dissecting  aneurism,  329. 
Distention,   dislocations   by,   301. 

of  bowel  in  diffuse  purulent  peritonitis,  714. 
Distortion,  295. 

Disturbances  of  nutrition,  291. 
Diverticula,  267. 

of  esophagus,  617. 
deep-seated,  619. 

of  upper  portion  of  esophagus,  pulsion,  618. 
Division  of  phrenic  nerve,  542. 

of  spinal  accessory  nerve,  542. 
Dog-nose,  446. 
Dry  senile  gangrene,  205. 
Duodenum,  injuries  of,  743. 
Duodenal  fistula,  702. 
Dura  mater,  inflammation  of,  430. 
venous  sinuses,  431. 

sarcomata  from,  415. 
Dyspnea,  fatal,  243. 

Ear,  abscess  in  soft  parts  of.  517. 
deafness  following  injury   to,  505. 
examination  of,  506. 
external,  accumulated  cerumen  in,  504. 

atresia  of,  502. 

congenital  abnormalities  of,  446. 

congenital  defects  of,  501. 

diffuse  inflammation  of,  503. 

direct  inspection  of,  500. 
51 


Ear,    external,    foreign    bodies    in,    504. 
furuncle  of,  503. 
injuries  of,  501. 
keloid  of,  502. 

perichondritis  of  cartilages  of,  502. 
tumors  of,  502. 
wounds  of,  503. 
insane,  502. 

inspection    through   speculum    of    canal    of, 
506. 
of  tympanic  membrane  of,  506. 
leptomeningitis  of,  517. 

middle,  acute  suppurative  inflammation  of, 
512. 
chronic  inflammation  of,  513. 

course  of  disease,  515. 
tuberculosis  of,  516. 
Valsalva's  method  of  inflating,  512. 
tests  of  bony  conduction  of,  508. 
Rinne's  test,  509. 
Weber's  test,  509. 
wax  in,  507. 

wax  in  external  auditory  canal  of,  504. 
Eardrum,  normal,  507. 
Ecchymosis,  279. 
color  changes  in,  3. 
palpation  in,  2S0. 
Echinococcus  cysts,  268,  274. 
of  abdominal  wall,  700. 
of  bone,  269. 
of  neck,  565. 
of  lung,  663. 
of  pleura,  659. 
of  thoracic  wall,  654. 
of  thyroid  gland,  5.71. 
Ecthymatous  chancre,  312. 
Eczema  of  areola,  672. 
of  nipple,  672. 
of  scalp,  396. 
Edema  laryngis,  5S8. 
Edema,  malignant,  65,  202. 
Edematous  tumor  in  new-born,  387. 
Effusion,  into  knee-joint,  signs  of,  160. 
into  pericardium,  667. 

signs  and  symptoms  of,  667. 
Emaciation     and    weakness    in     stricture     of 

esophagus,  616. 
Embolism,  336. 

following  abdominal  operations,  767. 
of  lungs,  287. 

signs  and  symptoms  of,  337. 
Emphysema  of  loose  tissues  of  orbit,  460. 
Emphysematous  gangrene,  202. 
Empyema   of  antrum,  476. 
of  frontal  sinus,  443. 


786 


INDEX   OF    SUBJECTS 


Empyema  of  pleura,  G56. 
putrid,  657. 

of  scalp,  398. 
Encephalocele,  440. 
Enchondroma,  231. 

of  jaws,  477. 

of  ribs,  653. 

of  scalp,  404. 

of  sternum,  653. 
Endometrium,  occurrence  of  bacteria  in,  71. 
Endothelioma,  249. 

of  scalp,  404. 
Endothelio-sarcoma,  249. 
Enostosis,  233. 
Epidemic  parotitis,  521. 
Epilepsy,  439. 

Jacksonian,  439. 
Epiphysis,  separation  of,   181,  276. 
Epistaxis,  466. 

Epithelial  growth  of  abdominal  wall,  700. 
Epithelial  tumors,  252. 

of  face,  456. 
Epithelioma,      differences      of      extra-genital 
chancres  from,  317. 

infiltrating  form  of,  258. 

of  jaws,  478. 

of  lower  part  of  pharynx,  499. 

superficial   form  of,  257. 

ulcerating,  of  scalp,  398. 
Erysipelas  gangrenosum,  122. 
Erysipelas,  head  symptoms  accompanying,  395. 

of  mucous  membrane  of  mouth,  484. 

of  scalp,  394. 

of  throat,  496. 

of  wounds,  120. 

complications  of,  122. 
constitutional  symptoms  of,  121. 
onset  of  the  disease,  120. 

phlegmonous,    182. 
Erysipelas  phlegmonosum,  122. 
Erysipeloid,  synonyms  of,  143. 
Erythromelalgia,  205. 
Eschars  produced  by  arsenious  acid,  750. 
Eschars  produced  by  carbolic  acid,  750. 

by  caustic  alkalies,  750. 

by  corrosive  sublimate,  750. 

by  hydrochloric  acid,  750. 

by  nitric  acid,  750. 

by  oxalic  acid,  750. 

by  sulphuric  acid,  750. 
Esophageal  fistula,  607. 
Esophagus,  burns  of,  543. 

catarrhal  inflammations  of,  acute,  611. 
chronic,  611. 

cicatricial  strictures  of,  613. 


Esophagus,  congenital  defects  of,  602. 
congenital  stricture  of,  612. 
dilatations  of,  617. 
diseases  of,  611. 
diverticula  of,  617. 

deep-seated,  619. 
foreign  bodies  in,  608. 

diagnosis  of,  610. 
injuries  of,  603. 
methods  of  examining,  596. 

auscultation,  599. 

direct  inspection,  esophagoseopy,  599. 

palpation,  598. 

percussion,  599. 

with  bougies,  596. 

X-ray  examination,  601. 
methods  of  introducing  flexible  instruments 

into,  598. 
new  growths   in,  620. 
peptic  ulcer  of,  612. 
perforations  of,  605. 
polypoid  growth  in,  620. 

pulsion  diverticula  of  upper  portion  of,  618. 
relations  of,  595. 
ruptures  of,  G05. 
spasmodic  strictures  of,  612,  613. 

nervous  origin  of,  614. 
spontaneous  rupture  of,  605. 
stricture  of,  612. 

diagnosis  of,  614. 

differential    diagnosis   between   cicatricial 
and  malignant,  615. 

due  to  malignant  growths,  612. 

emaciation  and  weakness  in,  616. 

pain  in,  616. 

physical  examination  in,  616. 

symptoms  of,  613. 
syphilitic  ulceration  of,  612. 
topography  of,  595. 
traction,  diverticula  of,  620. 
tubercular  ulceration  of,  612. 
wounds  of,  543. 
Estimation  of  red  cells  in  blood   (Ewing),  52. 
Ethmoid  cells,  fractures  through,  411. 
Eustachian  tube,  catheterization  of,  510. 

first  method   of,   510. 

second  method  of,  510. 
Politzer"s  method  of  testing,  511. 
Examination,  in  stricture  of  esophagus,  physi- 
cal, 616. 
of  contused  wounds,  6. 
of  ear,  506. 
of  hematomata,  387. 
of  lacerated  wounds,  5. 
of  larynx,  580. 


INDEX    OF    SUBJECTS 


787 


Examination  of  trachea,  580. 

of  wounds  in  diagnosis,  392.     . 
Exophthalmic  goiter,  r>(i(.). 

signs  and  symptoms  of,  509. 
nervous,  509. 
Exostosis,  233. 

bursata,  234. 
Expansile  pulsation,  330. 
Explosions,  injuries  caused  by,  390. 
Explosive  effect  of  gunshot,  28. 
Extra-genital  chancre,  313. 

differences  of,  from  epithelioma,  317. 

Face,  acne  rosacea  of,  455. 

actinomycosis  of.     See  Actinomycosis. 

clinical  diagnosis  of,   139. 
adenoma  of  sweat  glands  of,  457. 
angiomata  of,  455. 
anthrax  of,  450. 
burning  of,  448. 
carbuncle  of,  449. 
carcinoma  of,  457. 

deep  or  infiltrating  form  of,  459. 
congenital  defects  of,  445. 

rare,  446. 
cystic  lymphangioma  of,  455. 
dermoid  cysts  of,  457. 
diseases  of,  449. 
epithelial  tumors  of,  45G. 
erysipelas  of.     See  Erysipelas, 
fibroma  molluscum  of,  453. 
fibroma  of,  453. 

soft,  453. 
freezing  of,  449. 
furuncle  of,  449. 
glanders  of.  450. 
gummata  of,  452. 
gunshot  wounds  of,  447. 

dangers  of,  447. 
horns  of,  456. 
injuries  of,  447. 
keloid  of,  453. 
lipoma  of,  453. 
lupus  of.     See  Lupus, 
lymphangioma  of,  454. 
macrocheilia,  454. 
noma  of.     See  Noma, 
sarcoma  of,  454. 
sebaceous  cysts  of,  456. 
syphilis  of,  451. 

secondary  lesions  of,  451. 

tertiary  lesions  of,  452. 
tetanus  of.  448. 
tumors  of,  453. 
wounds  of,  447. 


Facial   muscles,  paralysis  of,  463. 
Facial  nerve,  injuries  of,  428. 

paralysis  and  spasm  of,  462. 
symptoms  of,  462. 
False  neuroma,  230. 
Farcy  buds,  145. 
Fat  embolism,  287. 
Fatty  tumor,  227. 
Faulty  union,  291. 
Fecal  fistula,  759. 
Fetal  rachitis,  193. 
Fibro-adenoma,  254. 

of  breast,  681. 
Fibroma,  228. 

molluscum,  229. 
of  face,  453. 

nasopharyngeal,  498. 

of  abdominal  wall,  698. 

of  face,  453. 
soft,   453. 

of  larynx,  591. 

of  neck,  566. 

of  salivary  glands,  524. 

of  scalp,  402. 

periosteal,  231. 
Fibro-sarcoma,  248. 

of  jaws,  477. 

of  salivary  glands,  524. 
Fibrous  goiter,   577. 
Fibrous  polypus,  498. 
Fibrous  tumor,  228. 

of  nasopharynx,  498. 
Fibrous  union,  291. 

Fifth  pair  of  cranial  nerves,  injuries  of,  428. 
Fifth  and  seventh  pairs  of  cranial  nerves,  af- 
fections of,  461. 
Fighter's  ear,  502. 
Finger,  chancre  of,  318. 
Fissure  of  Rolando,  421. 

of  Sylvius,  422. 

parieto-occipital,  422. 
Fissured   fractures  of   skull    with   generalized 
brain  injury,  409. 

symptoms  of,  410. 
Fissures,  275. 

localization  of,  in  brain,  422. 

of  skull,  405. 
Fistula,  duodenal,  762. 

esophageal,  607. 

fecal,  759. 

gastric,  755. 

of  larynx,  590. 

of  trachea,  590. 

omphalomesenteric,    701. 

salivary,  518. 


788 


INDEX    OF    SUBJECTS 


Fistula?,  arising  from  imperfect  closure  of  sec- 
ond branchial  cleft,  diagnosis  of,  529. 
between  intestine  and  urinary  tract,  761. 
intestinal,  756. 
internal,  760. 

symptoms  of,  761. 
external,  756. 
Fixation   of   pelvic   structures  in   pelvic  peri- 
tonitis, 722. 
Flanks,  suppuration  in,  697. 
Flat  condylomata,  320. 
Fluctuation  in  acute  abscess,  82. 
Foci   of  suppuration,   localized,   diagnosis   of, 

79. 
Follicular  tonsillitis,  492. 
Foot,  madura,  142. 

Foreign  bodies  in  abdominal  wall,  694. 
in  air  passages,  583. 

diagnosis  of,  586. 
in  brain,  429. 
in  cavity  of  nose,  469. 
in  esophagus,  608. 

diagnosis  of,  610. 
in  external  ear,  504. 
in  heart,  641. 

in  intestine,  diagnosis  of,  754. 
in  intestine  below  stomach,  753. 
in  mouth,  491. 
in  orbit,  460. 
in  pharynx,  491. 
in  salivary  ducts,  519. 

diagnosis  of,  519. 
in  stomach,  750. 

localization  of,  in  punctured  wounds,   10. 
Fractures,    active    or    determining    causes    of, 
272. 
bent  bone,  275. 
causation  of,  272. 
circumscribed,  of  skull,  405. 
complete.  275. 
complications  of,  286. 
compound.  276. 
course  of,  286. 
depressed,  of  skull,  406. 
due  to  direct  violence,  272. 
to  external  violence,  272. 
to  indirect  violence,  273. 
to  muscular  action,  273. 
fissured,  of  skull,  with  generalized  brain  in- 
jury. 409. 

symptoms  of,  410. 
green-stick,  275. 
gunshot,  277. 

of  skull,  408. 
incomplete,  275. 


Fractures,  intrapartum,  274. 

intra-uterine,  274. 

multiple,  276. 

objective  signs  of,  277.  • 

of  alveolar  border,  471. 

of  bones  of  nose,  463. 

of  cartilages  of  trachea,  536. 

of  costal  cartilages,  647. 

of  dislocated  bone,  296. 

of  hyoid  bone,  535. 

of  larynx,  535. 
signs  of,  535. 
Fractures  of  lower  jaw,  471. 

of  malar  bone,  471. 

of  ribs  and  cartilages,  645. 
diagnosis  of,  646. 

of  sternum,  643. 
diagnosis  of,  644. 

of  thorax,  643. 

of  upper  jaw,  470. 

of  zygomatic  process,  471. 

pathological,  273. 

period  required  for  union  of,  291. 

predisposing  causes  of,  272. 

spontaneous,  180,  273. 

subjective  symptoms  of,  286. 

through  ethmoid  cells,  411. 

through  frontal  sinus,  411. 

through  mastoid  cells,  411. 

varieties  of,  274. 
Freezing  of  face,  449. 
Frontal  lobes  of  brain,  420. 
Frontal    sinus,    acute    catarrhal    inflammation 
of,  443. 

diseases  of,  442. 

empyema   of,  443. 

fractures  through,  411. 

injuries  of,  442. 

tumors  of,  443. 
Function,  loss  of,  285. 

in  acute  osteomj'elitis,  180. 
Fungus  cerebri,  430. 
Furuncle,  74. 

of  external  ear,  503. 

of  face,  449. 

of  scalp,  396. 

Gangrene,  288. 

acute  emphysematous,  produced  by  Bacillus 

aerogenes  capsulatus,  95. 
causation  of,  199. 
course  of,  200. 
diabetic,  203. 

varieties  of,  204. 
dry  senile,  205. 


INDEX    OF    SUBJECTS 


789 


Gangrene  due  to  arteriosclerosis  in  early  mid- 
dle life,  205. 

emphysematous,  202. 

Foudroyante,  202. 

from  embolism   of  main   artery  of  a   limb, 
205. 

from  escharoties,  208. 

from  injuries  and  diseases  of  nervous  sys- 
tem, 212. 

from   thrombosis   of  main   artery   of   limb, 
205. 

hospital,  216. 

diphtheritic  form  of,  217. 
pulpy  form  of,  217. 
ulcerating  form   of,  217. 

in  contused  wounds,  7. 

moist,  201. 

of  lung,  660. 

constitutional   symptoms   of,  661. 

of  soft  parts,  199. 

of  umbilicus,  215. 

of  vulva,  215. 

presenile,  205. 

symmetrical,  215. 

symptoms  of,  200. 

traumatic,  201. 
Gangrenous  appendicitis,  99. 
Gangrenous  stomatitis.     See  Noma. 
Gastric  fistula,  755. 
Gastro-enteritis,  acute,  716. 
General  cortex  of  brain,  420. 
Genital  chancres  in  women,  diagnosis  of,  317. 
Giemsa  stain,  305. 
Gingivitis,  473. 

causes  of,  474. 
Glanders,  diagnosis  of,  144. 

in  man,  145. 
acute,  146. 
chronic,  146. 
modes  of  infection  of,   146. 

in  horse,  symptoms  of    (Youatt),  145. 

of  face,  450. 

synonyms  of,  144. 
Glandular  cancer   (Billroth),  259. 
Glioma,  238. 
Goiter,  572. 

colloid,  577. 

differential  diagnosis  of,  575. 

fibrous,  577. 

laryngoscopic  examination  of,  576. 

symptoms  of,  574. 
Gonorrhea  of  cavity  of  nose,  468. 
Gonorrheal   peritonitis,   719. 
Gonorrheal  rheumatism,  173. 
Gout,  176. 


Granuloma  of  jaws,  477. 

Graves's  disease,  569. 

Green-stick  fractures,  275. 

Gruber  specula,  506. 

Gullet,   phlegmonous    inflammation  of,  611. 

symptoms  of,  611. 
Gummata,  323. 

of  brain,  437. 

of  face,  452. 

of  mamma,  680. 

of  mucous  membrane  of  mouth,  484. 

of  scalp,  398. 

of  skin,  324. 

ulcerating,  324. 
Gummatous  periostitis,  413. 
Gums,  inflammation  of,  473. 
Gunshot,  effects  of  lodgment  of,  31. 

effects  of,  upon  various  tissues,  27. 

explosive  effect  of,  28. 
Gunshot  fractures,  277. 

of  skull,  408. 
Gunshot  wounds,  23. 

aseptic  healing  of,  29. 

hemorrhage  in,  29. 

of  abdomen,  735,  737. 

of  abdominal  wall,  694. 

of  diaphragm,  737. 

of  face,  447. 

dangers  of,  447. 

of  heart,  640. 

diagnosis  of,  640. 

of  intestine,  737. 

of  kidney,  737. 

of  lung,  634,  636,  737. 

of  mouth,  dangers  of,  447. 

of  neck,  537,  604. 

of  pleura,  737. 

of  scalp,  391. 

of  wall  of  thorax,  629. 

produced  by  automatic  pistols,  33. 
Gut,  rupture  of,  744. 

Hard  chancre,  308. 

Hard  papilloma,  252. 

Hard   sore,  310. 

Harelip,  445. 

Heart,  foreign  bodies  in,  641. 

gunshot  wounds  of,  640. 
diagnosis  of,  640. 

septic  infections  of,  102. 

wounds  of,  640. 
penetrating,  637. 
Heat  in  acute  abscess,  80. 
Hemangiomata   of  thoracic  wall,  652. 
Hemarthros  in  hemophilia,  172. 


790 


INDEX    OF    SUBJECTS 


Hematocytometer,  53. 

directions  for  using,  54. 
Hematogenous  infection  of  wounds,  1. 
Hematoma,  arterial,  10,  329. 
symptoms  of,  10. 

associated  lesions  of,  387. 

examination  of,  3S7. 

primary  aneurismal,  329. 

secondary  aneurismal,  329. 
Hemophilia,  49. 

hemarthros  in,  172. 

symptoms  of,  49. 
Hemorrhage,    from    alimentary    canal,    follow- 
ing  abdominal   operations,    763. 

from   middle    meningeal    artery   in    circum- 
scribed fractures  of  skull,  408. 

in  contused  wounds,  absence  of,  6. 

in  gunshot  wounds,  29. 

intracranial,  between  dura  and  pia,  427. 

of  wounds,  47. 

blood  changes  after    (Ewing),  50. 
from  arteries,  47. 
from  veins,  48. 

severe,  certain  effects  of,  51. 
Hemothorax,  658. 
Hernia  cerebri,   440. 

diagnosis  of,  442. 

varieties  of,  441. 
Hernia  of  lung,  624. 
Herpes,  315. 

of  throat,  493. 

of  tonsils,  493. 
Hiccough  in  diffuse  purulent  peritonitis,  714. 
High-powered  bullets,  straight  path  of,  30. 
Histological   examination   of   blood    (Ewing), 

109. 
History  of  accident,  286. 

of  dislocations,  298. 

of  patient,  286. 
Hodgkin's  disease,  240. 

differential  diagnosis  of,  243. 
Horns  of  face,  456. 
Hospital  gangrene,  216. 
diphtheritic  form  of,  217. 

pulpy  form  of,   217. 

ulcerating  form  of,  217. 
Hunterian  chancre,  308,  310. 
Hydatid  cyst,  268. 
Hydrencephalocele,  440. 
Hydroceles,  267. 
Hydrocephalus,  429. 

acquired,  439. 

congenital,  439. 

localized,  439. 

of  ventricles,  440. 


Hydrochloric  acid,  eschars  produced  by,  750. 
Hydrops  of  antrum,  476. 

of  joints,  intermittent,  170. 
Hydrops  tuberculosis  fibrinosum,  163. 
Hydrothorax,  658. 
Hyoid  bone,  fracture  of,  535. 
Hyperplasia,  inflammatory,  of  lymph  nodes  of 
neck,  551. 

of  cervical  lymph  nodes  of  neck,  551. 
Hyperplastic   form   of  tuberculosis    of   lymph 

glands  of  neck,  554. 
Hyperplastic  inflammation  of  glands  of  neck, 

555. 
Hypertrophic  rhinitis,  467. 
Hypertrophy  of  breast,   680. 

of  skull,  414. 

of  tonsils,  495. 
Hypoglossal  nerve,  wounds  of,  542. 
Hysterical  joints,  167. 

Identification    of    actinomycosis    by    cultures 

(Wright),  141. 
Ileum,  injuries  of,  743. 
Incised  wounds  of  scalp,  390. 
Induction  coils,  advantages  of,  340. 
Impaction,  294. 

Imperfect  ossification  of  skull,  414. 
Implantation  cysts,  265. 

Infection   and   inflammation   of   so-called   lin- 
gual tonsil,  486. 
Infection,  glanders,  in  man,  modes  of,  146. 
mixed,  of  tuberculosis  of  joints,  162. 

with    streptococci    and    saprophytic    bac- 
teria, 78. 
of    external    wound    following     abdominal 

operations,  765. 
of  penetrating  wounds  of  lung,  635. 

of  pleura,  633. 
of  umbilicus,   703. 

pyemia,  of  wounds,  methods  of,   114. 
secondary  tubercular,  151. 
septic,  local  signs  of,  93. 
of  alimentary  canal,  101. 
of  heart,  102. 
of  kidney,  102. 
of  liver,  102. 
of  lungs,  102. 
of  nervous  system,  102. 
of  skin,  102. 
of  spleen,  102. 

special  groups  of  symptoms  in,  101. 
with  syphilis,  310. 
Inflammation,  acute,  of  arteries,  334. 
acute,   of   breast,   673. 
diagnosis  of,  675. 


INDEX    OF    SUBJECTS 


791 


Inflammation,  acute,  of  breast,  symptoms  of, 
674. 
of  cranial  bones,  412. 
of  esophagus,  611. 
of  nasal  membrane,  467. 
of  periosteum,  412. 
of  thyroid  gland,  571. 
acute  catarrhal,  of  frontal  sinus,  443. 
acute  phlegmonous,  of  soft  parts  of  thorax, 

648. 
acute  suppurative,  of  middle  ear,  512. 
of  pia  mater,  432. 
of  submaxillary  gland,  522. 
catarrhal,  of  mucous  membrane  of  mouth, 

483. 
chronic,  of  arteries,  335. 
of  middle  ear,  513. 

course  of  disease,   515. 
of  neck,  551. 
of  salivary  glands,  520. 
of  tongue,  485. 
of  tonsils,  495. 
chronic  interstitial,  of  submaxillary  gland, 

522. 
diffuse,  of  external  ear,  503. 
hyperplastic,  of  glands  of  neck,  555. 
of  abdominal  wall,  695. 

deep-seated,  of,  695. 
of  blood-vessels,  334. 
of  breast,  673. 
of  dura  mater,  430. 
of  gums,  473. 
of  parotid  gland,  521. 
of  venous  sinuses  of  dura  mater,  431. 
phlegmonous,  76,  182. 

constitutional  symptoms  of,  76. 
of  gullet,  611. 

symptoms  of,  611. 
septic,  of  portal  vein,  99. 
tubercular,  of  skull,  412. 
of  thyroid  gland,  571. 
tuberculous,  of  salivary  glands,  523. 
Inflammatory  closure  of  jaws,  482. 
Inflammatory  diseases  of  larynx,  587. 
Inflammatory  effusions  in  diseases  of  pleura, 

156. 
Inflammatory    hyperplasia    of    lymph    nodes, 

551. 
Inflammatory  processes  of  neck,  543. 

of  umbilicus  in  infants  and  adults,  703. 
Innominate  artery  of  neck,  aneurisms  of,  558. 
Insane  ear,  502. 
Inspection  of  canal  of  ear  through  speculum, 

506. 
Inspection  of  dislocations,   298. 


Inspection    of    tympanic    membrane    of    ear 

through  speculum,  506. 
Intercostal  arteries,  wounds  of,  630. 
Intercostal  neuralgias,  651. 
Intracranial    hemorrhage,   between   dura   and 

pia,  427. 
Intermittent  claudication,  20."). 
Intermittent  hydrops  of  joints,  170. 
Internal  carotid  artery,  injury  of,  427. 
Internal   intestinal  fistulse,  symptoms  of,  761. 
Internal  mammary  artery,  wounds  of,  629. 
Intestinal  colic,  716. 
Intestinal  fistula,  756. 

external,  756. 

internal,  760. 
Intestinal  obstruction,   716.    ■ 

acute,    from   adhesion   bands  following   ap- 
pendectomy, 770. 

following  abdominal  operations,  768. 
Intestine,  bacteria  of   (Welch),  70. 

below  stomach,  foreign  bodies  in,  753. 

foreign  bodies  in,  diagnosis  of,  754. 

gunshot  wounds  of,  737. 

large,   ruptures   of,  748. 
wounds  of,  748. 

ruptures  of,  740. 

small,  bullet  wounds  of,  745. 
Intoxication,  putrid,  87. 
diagnosis  of,  88. 
symptoms  of,  87. 

septic,  90. 

as  result  of  errors  in  aseptic  technic,  91. 
constitutional  symptoms  of,  91. 
Intra-abdominal  bleeding,  symptoms  of,  735. 
Intramammary  abscess,  675. 
Intrapartum  fractures,  274. 
Intra-uterine  fractures,  274. 
Invasion  of  tetanus  of  wounds,  124. 
Iodoform  poisoning,  219. 
Ischemia,   regional,  214. 
Ischemic  contractures  of  muscles,  289. 

Jacksonian  epilepsy,  439. 
Jaw,  abscesses  at  angle  of,  548. 

actinomycosis  of,  475. 

actinomycosis  of  central  tissues  of,  139. 

acute  suppurative  periostitis  of,  474. 

acute  synovitis  of,  482. 

carcinoma  of,  480. 

fractures  of,  470. 

granuloma  of,  477. 

inflammatory  closure  of,  482. 

odontoma  of,  477. 

osteitis  of,  474. 

periostitis  of,  475. 


792 


INDEX    OF    SUBJECTS 


Jaw,  phosphorous  necrosis  of,   475. 
sarcomata  of,  479. 
tuberculosis  of,  475. 
tumors  of,  477. 

bodies  of,  478. 

carcinoma,  477. 

enchondroma,  477. 

epitheliomata,  478. 

fibro-sarcomata,  477. 

leontiasis  ossium,  479. 

malignant  diagnosis  of,  480. 

osteoma,  477. 

sarcoma,  477. 

symptoms  of,  481. 
Jejunum,  injuries  of,  743. 

Joints,  diagnosis   of   acute   exudative   lesions 
of,  174. 
differential    diagnosis    of    tuberculosis    from 

certain  other  diseases  of,  167. 
hysterical,  167. 
intermittent  hydrops  of,  170. 
mixed  infection   of  tuberculosis   of,  162. 
stiffness  of,  290. 
syphilis  of,   171. 
tuberculosis  of,  159. 

diagnosis  of,   164. 

differential  diagnosis  of,  165. 

Keloid,  229. 

of  external  ear,  502. 

of  face,  453. 

of  scalp,  402. 
Kidney,  gunshot  wounds  of,  737. 
Kidney,  septic  infections  of,  102. 

villous  tumor  of  pelvis  of,  254. 
Knee-joint,  later  symptoms  of  tuberculosis  of, 
161. 

signs  of  effusion  into,  160. 

tuberculosis  of,  160. 
Knee-joints,  bilateral  disturbance  of,  172. 
Kronlein,  method  of,  422. 
Kronlein's  craniometer,  423. 

Labyrinth,  symptoms  of  injuries  of,  505. 
Lacerated  wounds,  examination  of,  5. 

of  abdominal  wall,  694. 

of  scalp,  390. 
Laceration  of  brain,  428. 

symptoms  of,  429. 
Large  intestine,  ruptures  of,  748. 

wounrls  of,  748. 
Laryngocele,  583. 

Laryngoscopic     examination    of    bronehocele, 
570. 

of  goiter,  576. 


Larynx,  action  of  caustic  fluids  on,  583. 

examination    of,   580. 

fistula  of,  590. 

fracture  of,  535. 
signs  of,  535. 

inflammatory  diseases  of,  587. 

scalds  and  burns,  583. 

syphilis  of,  590. 

tuberculosis   of,   590. 

tumors  of  benign,  591. 
chondroma,  591. 
fibroma,  591. 
papilloma,  591. 
malignant,   592. 
carcinoma,  592. 

wounds  of,  583. 
Lead  poisoning,    474. 
Leontiasis  ossium,   198. 

of  jaws,  479. 
Leprosy,  326. 

anesthetic,  327. 

forms  of,  327. 

tubercular,  327. 
Leptomeningitis,  432. 

of  ear,  517. 
Leptothrix,   495. 

Leucocyte  count,  practical  value  of,  in  pyo- 
genic infections,  113. 
Leucocytes,  classification  of,  106. 

estimation  of  (Ewing),  108. 

morphology  of,  104. 

normal  variations  of,  112. 

proportions  of  various  forms  of,  108. 

varieties  of,  105. 

in  pathological  blood,  106. 
Leucoeytoses,  pathological,  113. 
Leucocytosis,  57. 

in  diffuse  purulent  peritonitis,  711. 

of  bones,  181. 

of  wounds,  103. 

diagnostic  value   of,   104. 
Leukoplakia  of  tongue,  486. 
Levaditi  stain,  305. 
Limitation  of  motion,  299. 
Lipoma,  227. 

of  abdominal  wall,  700. 

of  breast,  683. 

of  face,  453. 

of  neck,  566. 

of  salivary  glands,  524. 

of  scalp,  403. 
Liver,  secondary  abscesses  in,  99. 

septic  infections  of,  102. 
Local  cfl'ects  of  pyogenic  organisms,  73. 
Local  shock,  59. 


INDEX    OF    SUBJECTS 


793 


Local  signs  of  septic  infection,  93. 
Localization  of  fissures  in   brain,  422. 
Localized    foci    of    suppuration,    diagnosis  of, 

79. 
Localized    moist    gangrene,    signs   and    symp- 
toms of,  201. 
Localized  peritonitis,  717. 

caused  by  lesions  of  pancreas,  724. 

character  of  exudate  of,  717. 

course  of,  718. 

danger   of   delay  in   operating   in   cases   of, 

715. 
following  abdominal  operations,   767. 
secondary  to  inflammations  of  gall-bladder 

in,  723. 
subphrenic  abscess   in,   724. 

symptoms  and  diagnosis  of,  724. 
symptoms  of,   7 IS. 
Localizer  of  Mackenzie  Davidson,  360. 
Locked  jaws,  causes  of,  4S2. 
Lodgment  of  gunshot,  27. 

effects  of,  31. 
Long  axis  of  bone,  displacement  of,  293. 
Loss  of  function,  285. 

in  acute  osteomyelitis,  180. 
in  dislocations,  300. 
Lower  jaw,  dislocation  of,  472. 

bilateral,  signs  and  symptoms  of,  472. 
fractures  of,  471. 
Lung,  abscess  of,  659. 

physical  signs  of,  660. 
actinomycosis  of,  140,  663. 
diseases  of,  659. 
embolism  of,  287. 
gangrene  of,  660. 

constitutional  symptoms  of,  661. 
gunshot  wound  of,   634,  636,  737. 
hernia  of,  624. 

infection  of  penetrating  wounds  of,  635. 
septic  infections  of,  102. 
surgical  diseases  of,  diagnosis  of,  659. 
tuberculosis  of,   662. 
tumors  of,  benign,  664. 
carcinoma  of,  663. 
echinococcus  of,  663. 
sarcoma  of,  664. 
wound  of,  subcutaneous  emphysema  in,  634. 
nonpenetrating,  G30. 
penetrating,  633. 
Lupus,  150. 

characteristics  of,   150. 
course  of,   150. 
diagnostic  features  of,  150. 
hypertrophicus,  150. 
maculosus,  150. 


Lupus  of  Eace.     Sec  Lupus. 

of  scalp,  398. 

ulcerative  form  of,  150. 
Lymphangioma,  237. 

cavernous,  237. 
of  neck,  566. 
of  tongue,  487. 

cystic,  238. 
of  face,  455. 
of  tongue,  487. 

of  face,  454. 

of  salivary  glands,  524. 

of  thorax,  652. 

of  tongue,  487. 

simplex,  237. 
Lymphangitis  of  wounds,  94. 
Lymphatic  nerves,  237. 
Lymphatics  of  breast,  670. 
Lymph  glands,  tuberculosis  of,  153. 
Lynijfli  glands  of  neck,  546. 

hyperplastic  form  of  tuberculosis  of,  554. 

primary  sarcoma  of,  556. 

tuberculosis  of,  552. 
Lymph  nodes,  submental  abscesses  of,  548. 

in  parotid  gland,  tuberculous,  526. 

tuberculosis  of,  153. 
Lymph  nodes  of  neck,  deep,  abscesses  arising 
in,  548. 

inflammatory  hyperplasia  of,  551. 

secondary   carcinomatous  infection   of,  557. 
Lymphoma,  malignant,  155,  240. 
differential  diagnosis  of,  243. 
Lympho-sarcoma,  247. 

of  neck,  556,  568. 

Macrocheilia,  454. 

Microglossia,  487. 

Macroscopic  appearances  of  tumors,  226. 

Macrostoma,  446. 

Macular  syphilide,  318. 

Madura  foot,  142. 

synonyms  of,  42. 
Malar  bone,  fractures  of,  471. 
Malignant  edema,  202. 
Malignant  lymphoma,   155,  240. 

differential  diagnosis  of,  243. 
Malignant  pustule  of  scalp,  396. 
Malignant  tumors,  225. 

of  jaws,  diagnosis  of,  480. 
Malperforant,  212. 
Mamma,  gummata  of,  680. 

tuberculosis  of,  678. 
Mastitis,  acute,  673. 
diagnosis   of,   675. 
symptoms  of,  674. 


"94 


IXDEX    OP    SUBJECTS 


Mastitis,  acute  suppurative,  676. 
diagnosis  of,  675. 
symptoms  of,  674. 
chronic,  676. 
chronic   cystic,   677. 

clinical  characters  of.  677. 
Mastoid  cells,  fractures  through,  411. 
Mastoid,   osteomyelitis   of,   517. 
Mastoid  process,  primary  tuberculosis  of,  517. 
Mastoiditis,  515. 

pain  of,  516. 
Mechanical  closure  of  outlet  to  nose,  443. 
Mediastinals,   acute  suppurative,   665. 
fever  in.  665. 

pressure  symptoms  in,  665. 
chronic.  665. 
Mediastinum,  tumors  of,  665. 

symptoms   of,   666. 
Medullary  carcinoma,  261. 
Melano-sarcoma,  250. 
Melanuria.  251. 

Meningeal   artery,  middle  hemorrhage  in   cir- 
cumscribed   fractures   of   skull   from, 
408. 
Meningitis,  primary,  432. 

secondary,  433. 
Meningocele.  440. 
Mensuration.  283. 
Mercurial  poisoning,  474. 
Mesenteric   veins,   septic   thrombophlebitis   of, 

99. 
Mesentery,  ruptures  of.  744. 

wounds  of,  744. 
Meteorism  in  diffuse  purulent  peritonitis,  714. 
Methods  of  estimating  quantity  of  hemoglobin 
in  blood,  51. 
of  examination  in  abnormal  mobility,  281. 
of  examining  esophagus.  596. 
auscultation.  599. 

direct  inspection,  esophagoscopy,  599. 
palpation,   598. 
percussion.  599. 
with  bougies,  596. 
X-ray  examination,  601. 
of    introducing     flexible     instruments     into 

esophagus.  598. 
of    obtaining   and    caring    for    pathological 

material,  66. 
of  testing  hearing,  508. 
von  Mikulicz  disease,  523. 
Milium,  457. 
Milk,   retention  of.  676. 

Mixed  infection,  with  streptococci  and  sapro- 
phytic bacteria,  78. 
Mode  of  infection,  of  tuberculosis  of  bone,  157. 


Moist  gangrene,  201. 

localized,  signs  and  symptoms  of,  201. 
Moist  papules,  320. 
Moles,  266. 

Molluscum  contagiosum,  254. 
Molluscum  epitheliale,  254. 
Motor  area  of  cortex  of  brain,  418. 
Mouth,  congenital  deformities  of  floor  of,  484. 

diseases   of  mucous  membrane   of,  4S3. 

erysipelas  of  mucous  membrane  of,  484. 

foreign  bodies  in,  491. 

gummata  of  mucous  membrane   of,  484. 

gunshot  wounds  of,  dangers  of,  447. 

occurrence  of  bacteria  in,  69. 

primary  and  secondary  syphilitic  eruptions 
of  mucous  membrane  of,  4S4. 
Mucous  bursa3,  cystic   tumors  of,  564. 
Mucous  membrane,  nasal  diphtheria  of,  46S. 
pyogenic  germs  in,  69. 
tuberculosis  of,  468. 

of  mouth,  catarrhal  inflammation  of,  483. 
diseases  of,   483. 
erysipelas  of,  484. 
gummata    of,   484. 

primary    and   secondary    syphilitic    erup- 
tions of,  484. 

tuberculosis  of,  152. 
Mucous  membrane,  papules  upon,  321. 
Mucous  patches,  321. 
Multiplicity   of  chancre,   313. 
Mumps,   521. 
Muscle  tumor,  239. 
Muscles,   ischemic   contractures   of,  289. 

of  thorax,  congenital  deformities  of,  623. 

primary  tuberculosis  of,  157. 

rupture  of,   signs  of,  4. 

syphilis  of,   325. 

tuberculosis  of,  156. 
Myoma,  239. 

Myxedema  of  thyroid  gland,  570. 
Myxoma.   231. 

of  breast,  pure,  683. 

Nails,  in  secondary  syphilis,  321. 
Nasal  catarrh,  chronic,  467. 
Xasal  fossae,  abscess  of  submucous  tissues  of, 
468. 
syphilis  of,  468. 
tumors  of,  469. 

signs  and  symptoms  of,  470. 
Xasal  membrane,  acute  inflammation  of,  467. 
Xasal  mucous  membrane,  acute  inflammation 

of.  407. 
Nasal  mucous  membrane,  diphtheria  of,  468, 
tuberculosis  of,  468. 


INDEX    OF    SUBJECTS 


795 


Nasopharyngeal  fibroma,  498. 
Nasopharynx,   fibrous   tumors  of,   498. 
Neck,  actinomycosis  of,  551.     See  also  Actino- 
mycosis. 
clinical  diagnosis  of,  139. 
acute    suppurative    inflammatory    processes 

of,   547. 
anatomical   details   of  tissues  of    (Mcrkel), 

544. 
aneurisms  of  common  carotid  artery  of,  558. 
of  external  carotid  artery  of,  558. 
of  innominate  artery  of,  558. 
of  internal  carotid  artery  of,  558. 
of  subclavian  artery  of,  559. 
of  vertebral   artery  of,  560. 
arterio-venous   aneurisms   between   common 
carotid    artery    and    internal    jugular 
vein  of,  560. 
burns   of,   536. 

caseation  of  gland  tissue  of,  555. 
chronic  inflammations  of,  551. 
congenital  defects  of,  529. 
congenital  fistulse  of,  529. 

arising   from  imperfect  closure   of  second 

branchial  cleft,  529. 
arising  from  thyreo-glossal  duct,  530. 
gunshot  wound  of,  537,  604. 
hyperplasia  of  cervical  lymph  nodes  of,  551. 
hyperplastic  form  of  tuberculosis  of  lymph 

glands  of,  554. 
hyperplastic  inflammation  of  glands  of,  555. 
inflammatory  processes   of,  543. 
injuries  of,  534. 

subcutaneous,   534. 
lymph  glands  of,  546. 
lympho-sarcoma   of,   556. 
primary  sarcoma  of  lymph  glands  of,  556. 
secondary  carcinomatous  infection  of  lymph 

nodes  of,  557. 
syphilis  of  cervical  lymph  glands  of,  556. 
tissues  of,  543. 
tuberculosis  of  lymph  glands  of,  552. 

cases  in  which  infection  extends  to  peri- 
glandular tissues,  555. 
cases  in  which  infection  remains  confined 

to  gland  tissue  proper,  553. 
differential  diagnosis  of,  554. 
tumors  of,  cystic,  arising  from  thyreo-glos- 
sal duct,  563. 
blood  cyst,  564. 
branchiogenic   cysts,  562. 
cavernous  lymphangioma,  566. 
congenital  cystic  hygroma,  563. 
congenital  cystic  lymphangioma,  563. 
echinococcus,  565. 


Neck,  tumors  of,  cystic,  nevus  vasculosis,  565. 
of  mucous  bursa.',  504. 
of   second   cleft,   563. 
subcutaneous   atheromatous   cysts,  564. 
cystic  angioma,  565. 
cystic  angioma  cavernosum,  565. 
cystic   angioma   simplex  of,   565. 
malignant,   diagnosis  of,   561. 
solid  carcinoma,  568. 
chondroma,   567. 
fibroma,  566. 
lipoma,  566. 
lympho-sarcoma,  568. 
neuroma,  567. 
osteoma,  567. 
plexiform   neuroma,   567. 
sarcoma,  568. 
wounds  of,  536. 

wounds  of  blood-vessels  in  general  of,  537. 
wounds  of  nerves  in  general  of,  540. 
wounds  of  particular  blood-vessels  of,  538. 
wounds  of  veins  of,  539. 
Necrosis   of  jaws,   phosphorous,  475. 

of  skull,  414. 
Negri  bodies,  129. , 
Nephritic  colic,  716. 
Nerve,  acoustic,  injuries  of,  428. 
hypoglossal,  wounds  of,  542. 
phrenic,  division  "of,  542. 
pneumogastric,  wounds  of,  541. 
posterior   thoracic,   wounds    of,  542. 
spinal  accessory,  division  of,  542. 
Nerves,  in  general,  of  neck,  wounds  of,  540. 
injuries  of,  290,  297. 
symptoms  of,  4. 
motor,  4. 
sensory,  4. 
of  breast,  670. 

wounds  of,  fibroneuroma  from,   11. 
Nervous   system,  gangrene  from  injuries  and 
diseases  of,  212. 
septic  infections  of,  102. 
Neuralgia  of  breast,  680. 

of  fifth  pair  of  cranial  nerves,  461. 
Neuralgia,  intercostal,  651. 
Neurofibroma,  230. 

of  thorax,  652. 
Neurofibromata  of  scalp,  402. 
Neuroma.      See   Neurofibroma, 
false,  230. 
of  neck,  567. 
of  thorax,  652. 
plexiform,  238. 
Nevus  vasculosus,  235. 
of  neck,  565. 


796 


INDEX    OF    SUBJECTS 


Nevus  vasculosus  of  scalp,  402. 
Newborn,  cephalhernatomata  of,  388. 

edematous  tumor  in,  387. 
New  growth  in  esophagus,  620. 

polypoid,  620. 
Nipple,  atheromatous  cysts  of,  673. 

chancres   of,   317. 

depressed,  672. 

diseases  of,  672. 

eczema  of,  672. 

syphilis  of,  672. 

tumors  of,  pendulous,  673. 
Nitric  acid,  eschars  produced  by,  750. 
Xoma,  215. 

of  face,  451.     See  also  Noma. 
Noninfectious     effusions     in     pleural     cavity, 

658. 
Normal    eardrum,   507. 
Nose,  congenital  defects  of,  463. 

foreign  bodies  in  cavity  of,  469. 

fracture  of  bones  of,  463. 

gonorrhea  of  cavity  of,  468. 

injuries  and  diseases  of,  463. 

mechanical  closure   of  outlet  to,  443. 

perforating  ulcer  of  septum   of,  468. 
Nosebleed,  466. 
Nutrition,  disturbances  of,  291. 

Oculo-motor  nerve,  injuries  of,  428. 
Odontoma,  234. 

of  jaws,  477. 
Olfactory  nerve,  injuries  of,  427. 
Omentum,  wounds  of,  749. 
Omphalomesenteric  cyst,  701. 
Omphalomesenteric  diverticulum,  702. 
Omphalomesenteric  fistula,  701. 
Onychia,  321. 
Open  wounds  of  the  scalp,  389. 

anatomical  observations  in,  389. 
Optic  nerve,  injuries  of,  427. 
Orbit,  arterio-venous  aneurism  of,  460. 

emphysema  of  loose  tissues  of,  460. 

foreign  bodies  in,  460. 

injuries  and   diseases  of,  460. 

phlegmon  of,  460. 

wounds  of,  400. 
Ortho-form  dermatitis,  219. 
Osteitis  deformans,  196. 
Osteitis  of  jaws,  474. 

syphilitic  gummatous,  475. 
Osteoma,  233. 

of  jaws,  477. 

of  neck,  567. 

of  scalp,  404. 
Osteomalacia,  196. 


Osteomyelitis,  274. 
acute,   179. 

of  clavicle,  650. 
of  cranial  bones,  412. 
of  ribs,  650. 
of  sternum,  650. 
circumscribed,  187. 
of  mastoid,  517. 
sclerosing,  186. 
subacute,  183. 
syphilitic,  191. 
tuberculous,    188. 

signs  and  symptoms  of,   188. 
Otoscopy,  506. 
Ovarian   dermoids,  266. 
Overriding,  293. 

Oxalic  acid,  eschars  produced  by,  750. 
Ozena,  467. 

Pachymeningitis,  430. 
Pachymeningitis  externa,  517. 
Paget's  disease,  672. 
Pain    in    acute   abscess,   79. 

in  acute  osteomyelitis,  180. 

in  diffuse  purulent  peritonitis,  712. 

in  dislocations,  300. 

in  fractures,  285. 

in  stricture  of  esophagus,  616. 

in  tuberculous  osteomyelitis,  188. 

in  tumors,  224. 

of  mastoiditis,  516. 
Palate,  injuries  of,  490. 

soft,  tuberculosis  of,  152. 

tuberculosis  of,  496. 

tumors  of,  497. 
mixed,  497. 
Palm,  typical  phlegmon  of,  77. 
Palmar  syphilides,  323. 
Palpation  in  diffuse  purulent  peritonitis,  712. 

in  diseases  of  pleura,  655. 

in  dislocations,  299. 

in  eechymosis,  280. 

in  pelvic  peritonitis,  bimanual,  720. 
Papilloma,  252. 

hard,  252. 

of  larynx,  591. 

of  scalp,  400. 

soft,  253. 
Papular  syphilide,  319. 
Papules,  moist,  320. 

upon  mucous  membranes,  321. 
Papulo-squamous  syphilide,  320. 
Paralysis  and  spasm  of  facial  nerve,  462. 

symptoms  of,  462. 
Paralysis  of  abducens,  nerve,  428. 


INDEX    OF    SUBJECTS 


797 


Paralysis   of  bowel   in   diffuse   purulent  peri- 
tonitis, 714. 
Parasitic  cysts,  2G8. 
Parenchymatous  bleeding,  49. 
Parenchymatous  tonsillitis,  492. 
Parieto-occipital  fissure,  422. 
Parotid  gland,  inflammations  of,  521. 
injuries  of,  518. 

tuberculous  lymph  nodes  in,  52G. 
Partial   hypertrophies,  572. 
Pathological   character   of   pyogenic   bacteria, 

G7. 
Pathological  dislocations,  301. 
Pathological  fractures,  273. 
Pathological  leucocytoses,   113. 
Pathological    material,    methods    of  obtaining 

and  caring  for,  G6. 
Pelvic  peritonitis,  bimanual  palpation  in,  720. 
diagnosis  of,  720. 

fixation  of  pelvic  structures  in,  722. 
Pendulous  tumors  of  nipple,  G73. 
Penetration,  294. 
Peptic  ulcer  of  esophagus,  G12. 
Perforating  ulcer  of  septum  of  nose,  468. 
Perforation,   delayed,  from  contusion  of  wall 
of  gut,  741. 
of  esophagus,  G05. 
of  membrane  of  Shrapnell,  514. 
of  umbilicus  in  adults,  703. 
Perforation  and  lodgment  of  gunshot,  27. 
Pericarditis,  purulent,  639. 
Pericardium,  diseases  of,  667. 
effusions  into,  667. 

signs  and  symptoms  of,  667. 
injuries  to,  symptoms  of,  638. 
wounds  of,  penetrating,  637. 
Perichondritis  of   cartilages    of   external    ear, 
502. 
of  laryngeal  cartilages,  589. 
Pericranitis  acuta,  412. 

Periglandular  tissues,  infection  of,  with  pyo- 
genic microbes,  555. 
Period  of  incubation  of  syphilis,  309. 
Periosteal  fibroma,  231. 
Periosteum,  acute  inflammation  of,  412. 
Periostitis,  186. 

acute  suppurative,  of  jaws,  474. 
albuminosa,  186. 
gummatous,  413. 
of  jaws,  475. 
syphilitic,  189,  651. 

of  cranial  bones,  413. 
tuberculous,  650. 
Periphlebitis,  333. 
Pcripleuritic   abscesses   of  thoracic   wall,   649. 


Peritoneal  exudate,  physical  signs  of,  in  peri- 
tonitis, 714. 
Peritoneum,  behavior  of,  when  exposed  to  in- 
fection and  trauma,  706. 
general  considerations  of,  705. 
injuries  of,  732. 

general  and  special  data  of,  736. 
sources  of  infection  of,  706. 
Peritonitis,   aseptic,   731. 
bacteria  causing,  706. 
chronic,  727. 

with  production  of  adhesions,  727. 
symptoms  of,  728. 
chronic    exudative    (Vierordt,    A.    Frsenkel, 

Lennander),  727. 
differential  diagnosis  of,  715. 
diffuse  purulent,  anorexia  in,  711. 
cerebration  in,  71 1. 
distention  of  bowel  in,  714. 
general   and  local  symptoms  of3  710. 
hiccough  in,  714. 
leueocytosis    in,    711. 
meteorism  in,  714. 
pain  in,  712. 
palpation  in,  712. 
paralysis  of  bowel  in,  714. 
point  pressure  in,  713. 
pulse  in,  710. 
temperature  in,  710. 
tympanites  in,  714. 
urine  in,  711. 
vomiting  in,  713. 
examination  per  rectum  or  per  vaginam  in, 

715. 
following  abdominal  operations,  766. 
gonorrheal,  719. 
localized,  717. 

caused  by  lesions  of  pancreas,  724. 

character  of  exudate,  717. 

course  of,  718. 

danger  of  delay  in  operating  in  cases  of, 

715. 
following  abdominal  operations,   767. 
secondary  to  inflammations  of  gall-blad- 
der, 723. 
subphrenic  abscess  in,  724. 

symptoms  and  diagnosis  of,  724. 
symptoms  of,  718. 
pelvic,  diagnosis  of,   720. 

fixation  of  pelvic   structures  in.   722. 
physical    signs    of    peritoneal    exudate    in, 

714. 
tuberculous,   728. 

symptoms  and  diagnosis  of,  729. 
varieties  of,   707. 


798 


INDEX    01'    SUBJECTS 


Peritonitis,  with  putrid  decomposition  of  ex- 
udate, progressive  purulent,  709. 
Peritonsillar  abscess,  493. 
Pharyngeal    Avail,    posterior,    tuberculosis    of, 

152. 
Pharynx,    acute   inflammatory    affections    of, 
491. 
differential  diagnosis  of,  493. 
foreign  bodies  in,  491. 
injuries  of,  490. 

stenoses  and  cicatricial  adhesions  in,  496. 
syphilis  of,  495. 
tuberculosis  of,  496. 
tumors  of,   mixed,  497. 
tumors  of  lower  part  of,  499. 
carcinoma,  499. 
epithelioma,  499. 
sarcomata,   500. 
varicose   veins  in,   497. 
Phlebitis,  acute,  335. 
Phlegmon,  diffuse,  77. 

of  orbit,  460. 
Phlegmon,  spreading,  77. 

typical,  of  palm,  77. 
Phlegmonous  erysipelas,  182. 
Phlegmonous  inflammation,  76,   182. 
constitutional  symptoms  of,  76. 
of  gullet,  611. 

symptoms  of,   611. 
Phlegmons,  circumscribed,  76. 
Phosphorous  necrosis  of  jaws,  475. 
Phrenic  nerve,  division  of,  542. 
Pia  mater,  acute  suppurative  inflammation  of, 

432. 
Plantar  syphilides,  323. 
Pleura,  diseases  of,  654. 
auscultation  in,  655. 
general   considerations  of,  654. 
inflammatory  effusions  in,  656. 
palpation   in,   655. 
empyema  of,  656. 
gunshot  wounds  of,  737. 
infection  of  penetrating  wounds  of,  633. 
putrid  empyema  of,  657. 
tumors  of,  658. 
actinomycosis,  659. 
echinococcus,  659. 
wounds   of,  nonpenetrating,  630. 
penetrating,  631. 

subcutaneous  emphysema  in,  634. 
symptoms  of,  631. 
Pleural  cavity,  noninfectious  effusions  in,  658. 
Pleuritis,  tuberculous,  657. 
Plexiform  angioma,  235. 
Plexiform  angiosarcoma,  249. 


Plexiform  neuroma,  238.    • 

of  neck,  567. 

of  scalp,  402. 
Pneumatocele  capitis,  399. 
Pneumogastric  nerve,  wounds  of,  541. 
Pneumonia,  289. 

following  abdominal  operations,  767. 
Pneumothorax,  subphrenic,  628. 
Point  pressure  in  diffuse  purulent  peritonitis, 

713. 
Poisoned  arrow  wounds,  21. 

characters   of,  21. 

symptoms  of,  21. 
Poisoning,  iodoform,  219. 

lead,  474. 

mercurial,   474. 
Politzer  specula,  506. 
Politzer's  method  of  testing  Eustachian  tube, 

511. 
Polypoid  growths  in  esophagus,  620. 
Portal  vein,  septic  inflammation  of,  99. 
Posterior  rhinoscopy,  465. 
Posterior  thoracic  nerve,  wounds  of,  542. 
Presenile  gangrene,  205. 
Previsceral  space,  545. 
Primary  aneurismal  hematoma,  329. 
Primary  meningitis,  432. 
Primary   sarcoma  of  lymph   glands   of   neck, 

556. 
Primary    secondary    syphilitic     eruptions    of 

mucous  membrane  of  mouth,  484. 
Primary  tuberculosis  of  mastoid  process,  517. 
Progressive    purulent   peritonitis   with    putrid 

decomposition  of  exudate,  709. 
Prolapse  of  brain  through  wound,  430. 
Psammomata,  267. 
Pseudoleukemia,  155,  240. 

differential  diagnosis  of,  243. 
Pulse,  following  abdominal  operations,  765. 

in  diffuse  purulent  peritonitis,  710. 
Punctured   wounds,   signs   of  infection   in,   11. 
Purulent  pericarditis.  639. 
Pus-producing  bacteria,  varieties   of   diseases 

caused  by,  60. 
Pustular  syphilides,  321. 
Pustule,  malignant,  of  scalp,  396. 
Putrid  empyema  of  pleura,  657. 
Putrid  intoxication,  87. 

diagnosis  of,  88. 

symptoms  of,  87. 
Pyemia,   88. 

cryptogenic,  117. 

of  wounds,  114. 

clinical  course  of.  115. 
differential   diagnosis   of,  118. 


INDEX    OF    SUBJECTS 


799 


Pyemia   of   wounds,   methods   of   infection   of, 
114. 
symptoms  of,  116. 
varieties  of,   114. 
Pyogenic   bacteria,  pathological   character  of, 

07. 
Pyogenic  germs,  occurrence  of,  in  female  ure- 
thra, 71. 
of,  in  male  urethra,  70. 
in  various  tissues,  68. 
upon  mucous  membranes,  69. 
upon  the  skin,  68. 
Pyogenic  infection  of  an  aneurismal  sac,  331. 
Pyogenic  infection  of  joints,  course  of  disease, 

175. 
Pyogenic    infections    in     punctured    wounds, 
diagnosis  of,  11. 
leucocyte  count  in,  practical  value  of,   113. 
sources  of  bacteria  in,  71. 
varying  severity  of,  66. 
Pyogenic  organisms,  local  effects  of,  73. 

toxic  and  other  effects  of,  72. 
Pyopneumothorax,  subphrenic,  628. 
Pyorrhea  alveolaris,  chronic,  473. 

Eabies,  126. 

animals  affected  with,  26. 

definition  of,  126. 

differential  diagnosis  of,  134. 

distribution  of,  126. 

incubation  of,  127. 

in  dogs,  clinical  diagnosis  of,  131. 
paralytic  type  of,   132. 
symptoms  of  furious  type,  131. 

in  man,  126. 

paralytic  stage  of,  133. 
paralytic  type,  134. 
premonitory   symptoms   of,    132. 
stage  of  excitement  of,  133. 

nature  and  distribution  of  contagion  of,  127. 

pathology  of,  128. 

postmortem  diagnosis  of,  128. 

synonyms  of,  126. 
Rachitis,  193,  273. 

Radiographs,  time  of  exposure  of,  351. 
Ranula,  265. 
Raynaud's  disease,  215. 
Recti,  suppuration  behind,  697. 
Rectum,  tuberculous  ulceration  of,  152. 
Red  cells,  estimation  of   (Ewing),  52. 
Redness  in  acute  abscess,  80. 

in  acute  osteomyelitis,   180. 

in  tuberculous  osteomyelitis,  189. 
Reflecting  stereoscope,  364. 
Refracting  stereoscope,  366. 


Regional  cyanosis,  214. 
Regional  ischemia,  214. 
Regional  rubor,  215. 
Retention  cysts,  263. 
Retention  of  milk,  076. 

Retention  of  urine  following  abdominal  opera- 
tions, 764. 
Retromammary  abscess,  675. 
Retropharyngeal  abscess,  494,  550. 

signs  and  symptoms  of,  550. 
Retropharyngeal    space,   abscesses   of,   551. 
Retrovisceral  space,  545. 
Rhabdomyoma,  240. 
Rheumatism,  acute  articular,  182. 

gonorrheal,  173. 
Rhinitis,  atrophic,  467. 

hypertrophic,  467. 
Rhinoscopy,  anterior,  465. 

posterior,   465. 
Ribs,  acute  osteomyelitis  of,  650. 

cervical,  symptoms   of,  531. 

congenital   deformities  of,  622. 

dislocations  of,  647. 
from  cartilages,  647. 

enchondromata  of,  653. 

separation   from   one   another  of  cartilages 
of,  648. 
Ribs  and  cartilages,  fractures  of,  645. 

diagnosis  of,  646. 
Ricochet,  deforming  effect  of,  upon  bullets,  25. 

effects  of,  31. 
Riggs's  disease,  473. 

Rinne's  test  for  bony  conduction  of  ear,  509. 
Riva  rocei  apparatus,  50. 
Rodent  ulcer,  257. 
Rotary  displacement,  293. 
Rubor,  regional,  215. 
Rupia,  322. 
Rupture  of  abdominal  muscles,  693. 

of  alimentary  tract,   740. 

of  esophagus,  605. 

of  gut,  744. 

of  intestine,  740. 

of  large  intestine,   748. 

of  mesentery,  744. 

of  muscles,  signs  of,  4. 

of  stomach,  740. 

Salivary    calculus    in    Wharton's    duct,   diag- 
nosis of,  520. 
Salivary  ducts,  cystic  dilatation  of,  523. 
foreign  bodies  in,  519. 

diagnosis  of,  519. 
formation  of  calculi  in,  519. 
Salivary  fistula,  518. 


800 


INDEX    OF    SUBJECTS 


Salivary  glands,  cysts  of,  524. 
inflammations  of,  520. 
syphilis  of,  523. 
tuberculosis  of,  523. 
tuberculous  inflammation  of,  523. 
tumors  of,  524. 

adenoma,  527. 

angioma,  524. 

carcinoma,  527. 

soft  cellular  form  of,  528. 

fibroma,   524. 

fibro-sarcoma,  524. 

lipoma,  524. 

lymphangioma,  524. 

mixed,  524. 

diagnosis  of,  526. 

sarcoma,  524. 

scirrhus,  527. 

spindle-celled  sarcoma,  524. 
Sapremia,  87. 

combinations    of,   with    septic,    saprophytic, 

and  pyogenic  infection,  92. 
diagnosis  of,  88. 
symptoms  of,  87. 
Sarcoma,  244. 

differential     diagnosis     between     carcinoma 

and,  251. 
general  characters  of,  251. 
large  round-celled,  247. 
of  abdominal  wall,  699. 
of  brain,  437. 
of  breast,  683. 
of  dura,  415. 
of  face,  454. 
of  jaws,  477,  479. 
of  lower  part  of  pharynx,  500. 
of  lung,  664. 

of  lymph  glands  of  neck,  primary,  556. 
of  neck,  568. 
of  salivary  glands,  524. 
of  scalp,  404. 
of  skull,  415. 
of  thoracic  wall,  653. 
of  thymus  gland,  580. 
of  thyroid  gland,  578. 
of  tongue,  487. 
pigmented,  250. 
small  round-celled,  246. 
spindle-celled,  248. 

of  salivary  glands,  524. 
Scalp,  anatomical  observations  in  open  wounds 
of,  389. 

of  subcutaneous  wounds  of,  386. 
aneurisms  of,  399. 
anthrax  of,  390. 


Scalp,  arterial  supply  of,  389. 
birdshot   wounds   of,   391. 
carbuncle  of,  397. 
chancre  of,  398. 
contused  wounds  of,  390. 
diseases  of,  394. 
eczema  of,  396. 

edematous  tumors  of,  in  newborn,  387. 
emphysema  of,  398. 
erysipelas  of,  394. 
furuncles  of,  396. 
gummata  of,  398. 
gunshot  wounds  of,  391. 
hairy,  subcutaneous  abscesses  of,  395. 
incised  wounds  of,  390. 
lacerated  wounds  of,  390. 
lupus  of,  398. 

malignant  pustule  of,  396. 
open  wounds  of,  389. 
punctured  wounds  of,  391. 
secondary  macules  on,  398. 
subcutaneous  wounds  of,  386. 

signs  of  contusion,  386. 
syphilitic  lesions  of,  398. 
tuberculous  ulcers  of,  398. 
tumors  of,  400. 

angioma  simplex,  402. 

angiomata.     See  Cirsoid  Aneurism. 

atheromatous  cyst,  400. 

blood  cysts,  403. 

carcinoma,  402. 

dermoid  cyst,  400. 

enchondroma,  404. 

endotheliomata,  404. 

fibroma.  402. 

keloid,   402. 

lipoma,  403. 

neurofibromata,    402. 

nevus  vasculosus,  402. 

osteoma,  404. 

papillomata,  400. 

plexiform  neuroma,  402. 

sarcoma,  404. 

sebaceous  cyst,  400. 

ulcerating  epithelioma,   398. 
veins  of,  389. 
warts   of,   400. 
Scirrhous  carcinoma  of  breast,  686. 
Scirrhus,  of  salivary  glands,  527. 
Scirrhus  carcinoma,  261. 
Sclerosing  osteomyelitis,   186. 
Sclerosis,  of  tongue,  syphilitic,  486. 
Scurvy,  474. 

Sebaceous  cysts  of  scalp,  400. 
of  face,  456. 


IXDEX    OF    SUBJECTS 


801 


Secondary  aneurismal  hematoma,  329. 

Secondary  abscesses  in  liver,  90. 

Secondary   carcinomatous  infection   of  lymph 

nodes  of  neck,  557. 
Secondary  macules  on  scalp,  398. 
Secondary  meningitis,  433. 
Secondary  syphilis,  318. 
blood  in,  318. 
of  tongue,  486. 

typical,    characteristic   diagnostic    signs    of, 
31S. 
Secondary  tubercular  infections,   151. 
Sense  of  smell,  420. 

of  taste,  420. 
Sensory  field  in  brain,  419. 
Separation  of  an  apophysis,  275. 

of  cartilages  of  ribs  from  one  another,  648. 
of  epiphysis,  181. 
of  epiphyses,  276. 
of  splinter,  275. 
Septic  cellulitis,  77. 
Septic  diseases,  blood  cultures  in,  89. 
method  of  procedure  in  making  of,  90. 
typical  characters  of,  88. 
Septic  infection,  local  signs  of,  93. 
special  groups  of  symptoms  of,  101. 
in  alimentary  canal,  101. 
in  heart,  102. 
in  kidney,  102. 
in   liver,   102. 
in  lungs,  102. 
in  nervous  system,  102. 
in   skin,   102. 
in  spleen,  102. 
Septic  inflammation  of  portal  vein,  99. 
Septic  intoxication,  88,  90. 

as  result  of  errors  in  aseptic  technic,  91. 
constitutional  symptoms  of,  91. 
Septic  processes,  blood  in,  103. 
Septic    thrombophlebitis    of    mesenteric    veins 

99. 
Septicemia,  88,  2S7. 

produced  by  Bacillus  aerogenes  capsulatus, 

95. 
true,  signs  and  symptoms  of,  95. 
Septico-pyemia,  89. 
case  of,  98. 

from  appendicitis,  99. 
Sequestration  dermoids,  266. 
Shock,  57. 

after  contusions  of   abdomen,   692. 

cerebral,  424. 

conditions  modifying,  57. 

delayed,  58. 

following  abdominal   operations,  762. 


Shock,   hemorrhage   and,  58. 
local,  59. 

signs  and  symptoms  of,  57. 
Shotgun,  effects  of,  at  short  ranges,  43. 

wounds  produced  by.  43. 
Shrapnel,  46. 

wounds  produced  by,  47. 
Shrapnell's  membrane,  507. 

perforations  of,  514. 
Siegel's  pneumatic  otoscope.  508. 
Simple  hyperemia,  576. 
Simple  lymphangioma  of  tongue,  487. 
Sinuses,  of  brain,  injuries  of,  426. 
Skin,  effects  of  black  powder  upon,  34. 
fired  at  short  range,  33. 
effects  of  smokeless  powder  upon,  35. 

fired  at  short  range,  33. 
effects  of  discharge  of  pistols  upon,  loaded 

with  smokeless  powder,  34. 
gummata  of,  324. 
pyogenic  germs   in,   68. 
septic  infections  of,  102. 
tuberculosis   of,   150. 
Skin   cancer,  257. 

Skull,  aneurism  of  arteries  of,  415. 
atrophy  of,  414. 

circumscribed   fractures  of,  405. 
depressed  fractures  of,  406. 
diagnosis   of  injuries  of,  405. 
diseases  of,  412. 
fissures  of,   405. 

generalized  brain  injury  with  fissured  frac- 
tures of,  409. 
symptoms  of,  410. 
gunshot   fractures  of,  408. 
hemorrhage   from  middle  meningeal   artery 

in  circumscribed  fractures  of,  408. 
hypertrophy   of,   414. 
imperfect  ossification  of,  414. 
injuries  of,  diagnosis  of,  405. 
injuries  of  cranial  nerves  within,  427. 
necrosis  of,  414. 
sarcoma  of,  415. 

tubercular  inflammation  of,  412. 
Small   intestine,  bullet   wounds  of.  745. 
Smokeless  powders,  characters  of,  34. 
effects  of.  41. 

upon  linen,  gross,  37. 

microscopic.  39. 
upon  skin,  35. 

fired  at  short  range.  33. 
of  discharge  of  pistols  loaded  with,  34. 
Snake  bites.  13. 

cobra   poisoning,  symptoms  of.  19. 
mortalitv  in.  20. 


802 


IXDEX    OF    SUBJECTS 


Snake  bites,  of   colubrine  snakes,   13. 
of  viperidae,  15. 
rattlesnake,  symptoms  of,  18. 
treatment  of,  20. 
Snake  venom,  17. 
actions  of,  17. 
characters  of,  17. 
chemistry   of,    17. 
poisonous   principles   of,   17. 
blood-clotting,   18. 
hardening  of  blood  cells,  19. 
hemon'hagic,  18. 

loss  of  bactericidal  power  of  blood,  19. 
neurotoxin,  18. 
solution  of  blood  cells,  19. 
solution  of  tissue  cells,  19. 
Snakes,  cobra,  14. 
African,    15. 
Indian,  15. 
bush  master,  16. 
erotalus,   15. 

varieties  of,  15. 
fer  de  lance,  16. 
land,   14. 
krait,  14. 
moccasin,  16. 
sea,  14. 
viperidal.   15. 
habitat  of,  16. 
varieties  of,  16. 
pit  vipers,  15. 
Snakes'  teeth,  arrangement  of,  13. 
Soft  fibroma  of  face,   453. 
Soft-nosed  bullets,  diagnosis  of,  33. 

effects  of,  32. 
Space  of  Ketzius,  tuberculosis  of,  697. 
Space,  surrounding  the  great  vessels,  545. 
Spasmodic  strictures  of  esophagus,  612,  613. 

of  nervous  origin,  614. 
Spasmodic  torticollis,   533. 
Spasms  of  facial  muscles,  463. 
Special   groups   of  symptoms   in   septic   infec- 
tions. 101. 
of  alimentary  canal,  101. 
of  heart,   102. 
of  kidneys,  102. 
of  liver,  102. 
of  lungs,  102. 
Speech  areas  in  brain,  420. 
of  skin.  102. 
of  spleen,  102. 
Spina  ventosa,  158. 

Spinal  accessory  nerve,  division  of,  542. 
Spirocheta  pallida.  303. 
diagnosis  of,  306. 


Spirocheta   pallida,   distribution   and  fate  of, 
308. 

methods  of  staining  of   (Keyes),  305. 

occurrence  of,  306. 

tissue  stain  of,  305. 
Spirochete  in  hereditary  syphilis,  307. 

in   later  secondary  lesions  of  syphilis,   307. 

in  tertiary  syphilitic  lesions,  307. 
Spleen,  septic  infections  of,  102. 
Splinter,  separation  of,  275. 
Spontaneous  dislocations,  301. 
Spontaneous  fractures,  180,  273. 
Spontaneous  rupture   of  esophagus,  605. 
Sprain,  295. 

Spreading  septic  phlegmon,  77. 
Stab  wounds  of  abdomen,  734,  735. 
Static  machines,  disadvantages  of,  340. 
Status  lymphaticus,  579. 
Steno's  duct,  cysts  of,  523. 

injuries  of,  518. 
Stenoses,  of  larynx,  chronic,  590. 

of  trachea,  chronic,  590. 
Stenoses  and  cicatricial  adhesions  in  pharynx, 

496. 
Stereoscope,  refracting,  366. 

Wheatstone  reflecting,  364. 
Stereoscopic  radiographs,  299. 
Sternum,  acute  osteomyelitis  of,  650. 

congenital  deformities  of,  622. 

dislocations  of,  645. 

enchondromata  of,  653. 

fracture  of,  643. 
diagnosis  of,  644. 
Stings  of  insects,  22. 
Stomach,  bacteria  of  (Welch),  70. 

bullet  wounds  of,  745. 

foreign  bodies  in,  750. 
Stomach,  injuries  of,  740,  743,  745,  748. 
from  within,  749. 

ruptures  of,  740. 

untreated   wounds  of,  prognosis  of,  733. 
Stomatitis,  catarrhal,  483. 

gangrenous.     See  Noma. 

ulcerative,  483. 
Straight  path  of  high-powered  bullets,  30. 
Stricture  of  esophagus,  612. 

cicatricial.    613. 

diagnosis  of,  614. 

differential     diagnosis     between     cicatricial 
and  malignant,  615. 

emaciation  and  weakness  in,  616. 

pain  in,  616. 

physical   examination  in,  616. 

spasmodic,  613. 

symptoms  of,  613. 


INDEX    OF    SUBJECTS 


803 


Subacute  osteomyelitis,  183. 

case  of,  183. 

subsequent  history  of,  184. 
Subclavian  artery  of  neck,  aneurisms  of,  559. 
Subcutaneous  abscesses  of  hairy  scalp,  395. 
Subcutaneous  injuries,  2. 

ecchymosis  in,  3. 

effused  blood  in,  3. 

of  abdominal  contents,  739. 

groups  of  symptoms  observed  in,  739. 

of  muscles,  3. 

of  nerves,  4. 

of  tendons,  4. 

of  thorax,  G25. 

physical  signs  of,  627. 

pain  in,  2. 

signs  and  symptoms  of,  2. 
Subcutaneous   wounds  of  the   scalp,  386. 
Sublingual  glands,  injuries  of,  518. 
Subluxation,  295. 

Submaxillary    glands,    acute    suppurative   in- 
flammation of,  522. 

chronic   interstitial   inflammation   of,   522. 

injuries  of,  518. 
Submaxillary  space,  545. 
Submental  lymph  nodes,  abscesses  of,  548. 
Subphrenic  abscess,  in  localized  peritonitis,  724. 

physical  signs  of,  724. 

symptoms  and  diagnosis  of,  724. 
Subphrenic  pneumothorax,  628. 
Subphrenic  pyopneumothorax,  628. 
Sulphuric  acid,  eschars  produced  by,  750. 
Suppuration,  localized  foci  of,  diagnosis  of,  79. 
Suppuration  behind  recti,  697. 
Suppuration  in  flanks,  697. 
Supraclavicular  region,  abscesses  in,  549. 
Suprasternal  space,  545. 
Surgical  tuberculosis,   147. 
Sweat  glands  of  face,  adenoma  of,  457. 
Swelling  in  acute  abscess,  81. 

in  acute  osteomyelitis,  180. 

in  tuberculous  osteomyelitis,  189. 
Symmetrical  gangrene,  215. 
Sympathetic  cord,  wounds  of,  541. 
Synovial  tuberculosis,  162. 

fibrinous  form  of,  163. 

purulent  form  of,  164. 

serous  form  of,  163. 
Synovites,  causation  of,  174. 
Synovitis,  181. 

catarrhal,  176. 

metastatic,   176. 

of  jaws,  acute,  482. 

syphilitic,  171. 

traumatic,  in  tabes,  168. 


Syphilides,  macular,  318. 
palmar,  323. 
papular,  319. 
papulo-squamous,  320. 
plantar,  323. 
pustular,  321. 
tubercular,  323. 
Syphilis,  274,   303. 

development  of  constitutional  symptoms  in, 

314. 
development    of   enlarged   lymph    nodes    in, 

313. 
diagnosis  in  early  stages  of,  316. 
differential  diagnosis  of,  from  chancre,  315. 

from  chancroid,  314. 

from  herpes  of  the  genitals,  315. 
hereditary,  326. 

bone  lesions  of,  192. 
immunity  from,  309. 
infection  with,  310. 
initial  lesion  of,  308. 
modes  of  contagion  of,  360. 
of   areola,   672. 
of  bone,  189,  326. 

differential  diagnosis  of,  192. 
of  cervical  lymph  glands  of  neck,  556. 
of  cranial  bones,  413. 
of  face,  451. 

secondary  lesions  of,  451. 

tertiary  lesions  of,  452. 
of  joints,  171. 
of  larynx,  590. 
of  muscles,  325. 
of  nasal  fossa?,  468. 
of  nipple,  672. 
of  pharynx,  495. 
of  salivary  glands,  523. 
of  shafts  of  long  bones,  165. 
of  thyroid  gland,  571. 
of  tongue,  485. 

secondary  manifestations  of,  486. 
of  tonsils,  495. 
period  of  incubation  of,  309. 
period   of  secondary  symptoms  of,  310. 
secondary,  310,  318. 

blood  in,  318. 

nails  in,  321. 

of  tongue,  486. 

typical,  characteristic  diagnostic  signs  of, 
318. 
secondary  symptoms  of,  318. 
spirochete  in  hereditary,  307. 

in  later  secondary  lesions  of,  307. 

in  tertiary  lesions  of,  307. 
symptoms  of,  308. 


804 


INDEX    OF    SUBJECTS 


Syphilitic  acne,  321. 

Syphilitic  alopecia,  398. 

Syphilitic  arthralgia,  171. 

Syphilitic  arthritis,  171. 

Syphilitic  ecthyma,   321. 

Syphilitic  gummatous  osteitis  of  jaws,  475. 

Syphilitic  impetigo,  321. 

Syphilitic  lesions  of  scalp,  398. 

Syphilitic  osteomyelitis,  191. 

of  flat  bones,  191. 
Syphilitic  periostitis,  189. 

of  cranial  bones,  413. 

of  ribs  and  sternum,  651. 
Syphilitic  roseola,  318. 
Syphilitic  sclerosis  of  tongue,  486. 
Syphilitic  synovitis,  171. 
Syphilitic  teeth,  326. 
Syphilitic   ulceration   of   esophagus,   612. 

Tabes,  traumatic  synovitis  in,  168. 
Teeth,  syphilitic,  326. 
Telangiectasis,    235. 

Temperature,  following  abdominal  operations, 
764. 
in  diffuse  purulent  peritonitis,  710. 
Temporo-maxillary    articulation,  arthritis   de- 
formans of,  482. 
diseases  of,  482. 
tuberculosis  of,  482. 
Tenderness  in  acute  abscess,  83. 
in  acute  osteomyelitis,  180. 
in  diffuse  purulent  peritonitis,  712. 
in  tuberculous  osteomyelitis,   188. 
Tendon    sheaths,  tuberculosis   of,    156. 
Tendons,  tuberculosis  of,  156. 

vitality  of,  6. 
Teratoma,  271. 

Tests  of  bony  conduction  of  ear,  508. 
Rinne's  test,  509. 
Weber's  test,  509. 
Tetanus,  289. 

differential   diagnosis  of,   125. 
invasion    of.    124. 
of  head,   125. 
subacute,  125. 
habitat  of  germ  of,  123. 
hydrophobicus,  125. 
of  face,  448. 
of  wounds,  122. 

acute   types  of,   123. 
chronic  types  of,  123,  125. 
course  of,  124. 
Thoracic  duct,  injuries  of,  642. 

wounds  of,  542. 
Thoracic  wall,  abscesses  of,  648. 


Thoracic  wall,  actinomycosis  of,  649. 
cold  abscesses  of,  649. 
diseases  of,  648. 
peripleuritic  abscesses  of,  649. 
tumors  of,  651. 
carcinoma,  654. 
echinococeus,  654. 
hemangiomata,  652. 
sarcoma,  653. 
Thorax,    acquired    congenital    deformities    of, 
623. 
acute    phlegmonous    inflammation    of    soft 

parts  of,  648. 
concussion  of,  628. 

congenital  cavernous  angioma  of,  652. 
congenital  deformities  of,  622. 
congenital  deformities  of  muscles  of,  623. 
contusions  of,  625. 
deformities  of,  622. 
fractures   and   dislocations  of.   643. 
gunshot  wounds  of  wall  of,  029. 
injuries  of,  625. 
subcutaneous,  625. 

physical  signs  of,  627. 
lymphangiomata  of,  652. 
neurofibroma  of,  652. 
neuroma  of,  652. 
wounds  of,  629. 

nonpenetrating,  629. 
penetrating,  630. 
wounds  of  great  vessels  of,  642. 
wounds  of  vessels  of,  629. 
Throat,  erysipelas  of,  496. 
herpes  of,  493. 
occurrence  of  bacteria  in,  69. 
Thrombosis,   336. 

following  abdominal  operations,  767. 
symptoms  of,  336. 
Thrush.  483. 
Thymus   gland,   diseases   of,   579. 

sarcoma  of,  5S0. 
Thyreo-glossal  duct,  cysts  arising  from,  563. 
Thyroid  gland,  acute  inflammation  of,  571. 
cretinism  of,  570. 
diseases  and  tumors  of,  569. 
echinococeus  of,  571. 
myxedema  of,  570. 
syphilis  of,  571. 

tubercular  inflammation  of,  571. 
tumors  of,  malignant,  578. 
carcinoma,  578. 
sarcoma,  578. 
Thyroid  glands,  accessory,  499. 
Tissues,  effects  of  cold   upon,  208. 
effects  of  heat  upon.  210. 


INDEX    OF    SUBJECTS 


805 


Tissues,  effects  of  heat  upon,  classification  of, 

210. 
general  symptoms  of,  210. 
effects  of  gunshot  upon,  27. 
pyogenic  germs  in,  08. 
Tissues  of   neck,  anatomical  details  of    (Mer- 

kel ) ,  544. 
Tongue,  acquired   atrophy  of,  484. 
actinomycosis  of,   140,  480. 
cancer  of,  488. 

diagnosis  of,  490. 
chancre  of,  485. 
congenital  deformities  of,  484. 
congenital  shortening  of  frenum  of,  484. 
congenitally  fissured,  484. 
dermoid  cysts  of,  488. 
inflammations  of,  485. 
injuries  of,  484. 
leukoplakia  of,  480. 
syphilis  of,  485. 

secondary,   486. 
syphilitic  sclerosis  of,  486. 
tuberculosis  of,  152,  485. 
tumors  of,  487. 
angioma,   487. 

cavernous,  487. 
angioma   simplex,  487. 
cystic,  488. 

ranula,  488. 
lymphangioma,  4S7. 
cavernous,  487. 
cystic,  487. 
simple,  487. 
rare,  488. 
Tonsillitis,  catarrhal,  492. 
follicular,  492. 
parenchymatous,  492. 
Tonsils,  acute  inflammatory  affections  of,  491. 
differential  diagnosis  of,  493. 
chancres  of,   317. 
chronic    inflammation   of,   495. 
herpes  of,  493. 
hypertrophy  of,  495. 
injuries  of,  490. 
occurrence  of  bacteria  in,  69. 
syphilis  of,  495. 
tuberculosis  of,  496. 
tumors  of,  497. 
mixed,  497. 
Tooth  tumors,  234. 
Topography  of  bullet  wounds,  29. 
Torticollis,  531. 

spasmodic,  533. 
Toxic  and  other  effects  of  pyogenic  organisms, 
72. 


Trachea,  action  of  caustic  fluids  on,  583. 
examination  of,  580. 
fistula  of,  590. 

fracture  of  cartilages  of,  536. 
scalds  and  burns  of,  583. 
tumors  of,  594. 
wounds  of,  583. 
i    Tracheocele,  583. 
Traction  diverticula  of  esophagus,  620. 
Traumatic  aneurism,  10. 

symptoms  of,  10. 
Traumatic  blood  cyst  of  scalp,  388. 
Traumatic  dislocations,  295. 

differential  diagnosis  of,  300. 
Traumatic  gangrene,  201. 
Traumatic  synovitis  in  tabes,  168. 
Trocar,    introduction   of,    through   abdominal 

wall,  715. 
Trochlear  nerve,  injuries  of,  428. 
Trophic  ulcer,  213. 

True  septicemia,  signs  and  symptoms  of,  95. 
Tubercle,  anatomical,  151. 
Tubercular  syphilides,  323. 
Tubercular  arthritis,  159. 
Tubercula  dolorosa,  230. 
Tubercular  inflammation  of  skull,  412. 

of  thyroid  gland,  571. 
Tubercular  ulceration  of  esophagus,  612. 
Tuberculosis,  clinical  diagnosis  of,  147. 

differential  diagnosis  of,  from  certain  other 

diseases  of  joints,   167. 
laboratory  identification  of  bacillus  of,  147. 
of  bone,  157. 
course  of,   158. 
diagnosis  of,  159. 
occurrence  of,  157. 
of  breast,  diffuse  miliary,  679. 
of  bursa?,  156. 
of  jaws,  475. 
of  joints,  159. 
of  knee-joint,   160. 

later  symptoms  of,  161. 
Tuberculosis  of  larynx,  590. 
of  lung,  662. 
of  lymph  glands,  153. 
characteristics  of,   153. 
differential  diagnosis  of,   154. 
of  neck,  552. 

cases    in    which    infection    extends    to 

periglandular  tissues,  555. 
cases   in   which   infection    remains    con- 
fined to  gland  tissue  proper,  553. 
differential   diagnosis    of,  554. 
of  the  lymph  nodes,  153. 
of  mamma,  678. 


806 


INDEX    OF    SUBJECTS 


Tuberculosis  of  mamma,  diagnosis  of,  678. 
of  mastoid  process,  primary,  517. 
of  the  middle  ear,  516. 
of  mucous  membrane,  152. 
of  muscles,  156. 

of  nasal  mucous  membrane,  468. 
of  the  palate,  496. 
of  pharynx,  496. 

of  posterior  pharyngeal  wall,  152. 
of  salivary  glands,  523. 
of  skin,  150. 
of  soft  palate,  152. 
of  space  of  Retzius,  697. 
of  temporo-maxillary  articulation,  482. 
of  tendon  sheaths,  156. 
of  tendons,  156. 
of  tongue,  152,  485. 
of  tonsils,  496. 
primary,  of  muscles,  157. 
surgical,   147. 
synovial,  162. 

fibrinous  form  of,  163. 
purulent  form  of,   164. 
serous  form  of,   163. 
Tuberculosis  verrucosa  cutis,  151. 
Tuberculous  disease  of  brain,  437. 
Tuberculous  inflammation  of  salivary  glands, 

523. 
Tuberculous   lymph    nodes   in   parotid   gland, 

526. 
Tuberculous  osteomyelitis,   188. 
signs  and  symptoms  of,  188. 
Tuberculous  periostitis,  650. 
Tuberculous  peritonitis,  728. 

symptoms  and  diagnosis  of,  729. 
Tuberculous  pleuritis,  657. 
Tuberculous  pus,  152. 
Tuberculous  ulceration  of  rectum,  152. 
Tuberculous  ulcers  of  scalp,  398. 
Tubular  cancer  of  breast,  685. 
Tubulo   dermoids,  266. 
Tumor  albus  or  white  swelling,  161. 
Tumor,  edematous,  in  new-born,  387. 
fatty,  227. 
fibrous,  228. 

villous,  of  bladder,  254. 
of  pelvis  of  kidney,  254. 
Tumors,  adenoid,  497. 
benign,  222. 
of    breast,    fibro-adenoma,    681. 
lipoma,  683. 
pure  myxoma,  683. 
of  larynx,  591. 
chondroma,   591. 
fibroma,  591. 


Tumors,   benign,  of   larynx,  papilloma,  591. 
of  lung,  664. 
bony,  233. 

connective-tissue,  227. 
cystic,  262. 

follicular,   264. 
mucous,  264. 
of  neck,  564. 

angioma  cavernosum,  565. 
angioma   simplex,  565. 
arising  from  thyreoglossal   duct,  563. 
blood  cyst,  564. 
branchiogenic  cysts,  562. 
cavernous  lymphangioma,  566. 
congenital  cystic  hygroma,  563. 
congenital   cystic   lymphangioma,   563. 
echinococcus,  565. 
of  mucous  bursas,  564. 
of  second  cleft,  563. 
retention,  265. 

subcutaneous  atheromatous   cysts,   564. 
definition  and  classification  of,  221. 
diagnosis  of,  224. 
epithelial,  252. 

macroscopic  appearances  of,  226. 
malignant,  222,  225. 
following  injury,  223. 
local  recurrence  of,  222. 
of  breast,  acinous  cancer,  685. 
adenocarcinoma,  686. 
carcinoma,  684. 
contraindications  to  operation  in,  690. 
practical  suggestions  in,  690. 
carcinoma  simplex,  685. 
colloid  cancer,  686. 
sarcoma,  683. 
scirrhous  carcinoma,  6S6. 
symptoms  of,  481. 
of  jaws,  diagnosis  of,  480,  561. 
of  larynx,  592. 

carcinoma,  592. 
of  thyroid  gland,  578. 
carcinoma,  578. 
sarcoma,   578. 
regional  recurrence  of,  222. 
mixed,  of  palate,  497. 
of  pharynx,  497. 
of  salivary  gland,  524. 

diagnosis  of,  526. 
of  tonsil,  497. 
muscle,  239. 
number  of,  225. 
occurrence  of,  223. 
of  abdominal  wall,  dermoid,  698. 
echinococcus,  700. 


INDEX    OF    SUBJECTS 


807 


Tumors  of  abdominal  wall,  epithelial  growths, 
700. 

fibroma,  698. 

lipoma,  700. 

sarcoma,  699. 
of  antrum,  477. 
of  brain,  436. 

general  symptoms  of,  438. 

gumma,  437. 

local  symptoms  of,  438. 

sarcoma,  437. 
of  breast,  cancer,  clinical   course  and  diag- 
nosis of,  686. 

cystosarcoma,  682. 
of   cranial   bones,  415. 
of  external  ear,  502. 
of  face,  453. 

carcinoma,  deep  or  infiltrating  form  of, 
459. 
of  frontal  sinus,  443. 
of  jaws,  477. 

bodies  of,  478. 

carcinoma,  477,  4S0. 
enchondroma,   477. 

epitheliomata,  478. 

fibro-sarcomata,  477-478,  479. 

leontiasis  ossium,  479. 
osteoma,   477. 

sarcoma,  477. 
of  larynx,  carcinomata,  500. 
of  lower  part  of  pharynx,   499. 

carcinoma,  499. 

epithelioma,  499. 

sarcomata,  500. 
of  lung,  carcinoma,  663. 

sarcoma,  664. 
of  male  breast,  690. 
of  mediastinum,  665. 

symptoms  of,  666. 
of  nasal  fossaj,  469. 

signs  and  symptoms   of,   470. 
of  nasopharynx,  fibrous,  498. 
of  nipple,   pendulous,  673. 
of  orbit,  460. 
of  palate,  497. 
of  pleura,  658. 

actinomycosis,  659. 

echinococcus,  659. 
of  salivary  glands,  524. 

adenoma,  527. 

angioma,  524. 

carcinoma,  527. 

soft  cellular  form  of,  528. 
fibroma,  524. 

fibro-sarcoma,  524. 


Tumors  of  salivary  glands,  lipoma,  524. 
lymphangioma,  524. 
sarcoma,  524. 
scirrhus,  527. 

spindle-celled  sarcoma,  524. 
of  scalp,  400. 

angioma   simplex,  402. 
angiomata*     See  Cirsoid  Aneurism, 
atheromatous  cyst,  400. 
blood  cysts,  403. 
carcinoma,  402. 
dermoid  cyst,  400. 
enchondroma,  404. 
endotheliomata,  404. 
fibroma,  402. 
keloid,  402. 
lipoma,  403. 
neurofibromata,  402. 
nevus  vasculosus,  402. 
osteoma,  404. 
papillomata,  400. 
plexiform  neuroma,   402. 
sarcoma,  404. 
sebaceous  cyst,  400. 
of  thoracic  wall,  651. 
carcinoma,  654. 
echinococcus,  654. 
hemangiomata,   652. 
sarcoma,  653. 
of  tongue,  487. 
angioma,  487. 

cavernous,  487. 
angioma  simplex,  487. 
cystic  ranula,  488. 
lymphangioma,  487. 

cavernous,  487. 

cystic,  4S7. 

simple,  487. 
rare,  488. 
sarcoma,  487. 
of  tonsil,  497. 
of  trachea,  594. 
of  umbilicus.  704. 
carcinoma,  704. 
pain   in,  224. 

relation  of,  to  surrounding  parts,  225. 
solid,  of  neck,  carcinomaj  568. 

chondroma,  567. 

fibroma,  566. 

lipoma,  566. 

lympho-sareoma,  56S. 

neuroma,  567. 

plexiform,  567. 

osteoma,  567. 

sarcoma,  568. 


808 


INDEX    OF    SUBJECTS 


Tumors,  tooth,  234. 

Tympanic  membrane,   injuries  of,  504. 

rupture  of,  505. 
Tympanites  in  diffuse  purulent  peritonitis,  7 14. 
Typhoid  fever,  182. 

Typical  characters  of  septic  diseases,  88. 
Typical  phlegmon  of  palm,  77. 

Ulcer  of  esophagus,  peptic,  612. 

of  septum  of  nose,  perforating,  468. 

rodent,  257. 

trophic,  213. 

tuberculous,  of  scalp,  398. 
Ulcerating  epithelioma  of  scalp,  39S. 
Ulcerating  gummata,  324. 
Ulceration,  tuberculous,  of  rectum,  152. 
Ulcerative  form   of   lupus,  150. 
Ulcerative  stomatitis,  483. 
Ulcus  durum,  310. 
Ulcus  elevatum,  311. 
Ulcus  molle,  314. 
Umbilicus,   congenital  anomalies  of,   701. 

diseases  of,  701. 

infection   of,   703. 

inflammatory  processes  in  infants  and  adults 
of,  703. 

gangrene  of,  215. 

perforations  of,  in  adults,  703. 

tumors  of,  704. 
carcinoma,  704. 
Union,  delayed,  291. 

failure  of,  291. 

faulty,  291. 

fibrous,  291. 

of  fractures,  period  required  for,  291. 
Upper  jaw,  fractures  of,  470. 
Urachus,  congenital  anomalies  of,  702. 
Uremia,  716. 

Urethra,  female,  occurrence  of  pyogenic  germs 
in,  71. 

male,  occurrence  of  pyogenic  germs  in,  70. 
Urine  in  diffuse  purulent  peritonitis,  711. 
Use  of  the  aspirating  needle,  83. 

in   diagnosis  of  acute  exudative  lesions  of 
joints,  174. 
Uterine  sepsis,  719. 
Uvula,  495. 

Vagina,   occurrence   of   bacteria   in,   71. 
Valsalva's  method  of  inflating  middle  ear,  512. 
Varicose  aneurism,  11,  329,  334. 
Varicose  veins,  337. 

in  pharynx,  497. 

of  leg,  signs  and  symptoms  of,  337. 
subjective,   338. 


Vein,  portal,  septic  inflammation  of,  99. 
Veins,   aspiration   of  air  into,  48. 

diseases  of,  335. 

dilatation  of,  in  acute  osteomyelitis,  ISO. 

hemorrhage  from  wounds  of,  48. 

mesenteric,  septic  thrombophlebitis  of,  99. 

varicose,  337. 
of  leg,  signs  and  symptoms  of,  338. 
subjective,  338. 

of  neck,  wounds  of,  539. 

of  scalp,  3S9. 
Venous  sinuses  of  dura  mater,  inflammation 

of,  431. 
Ventricles,  hydrocephalus  of,  440. 
Verruca,  252. 
Verruca  necrogenica,  151. 
Vertebral  artery  of  neck,  aneurisms  of,  560. 
Villous  tumor  of  bladder,  254. 

of  pelvis  of  kidney,  254. 
Visual  cortex  of  brain,  420. 
Vomiting  in  diffuse  purulent  peritonitis,   713. 
Vulva,  chancre  of,  313. 

gangrene  of,  215. 

Warts,  252. 
acuminate,  253. 
of  scalp,  400. 
Wax  in  ear,  507. 

Weber's  test  of  bony  conduction  of  ear,  509. 
Wharton's   duct,    salivary    calculus    in,    diag- 
nosis of,  520. 
Wheatstone  reflecting  stereoscope,  364. 
Wounds,  actinomycosis  of,  137. 
anthrax  of,   136. 
arterial  pressure  in,  50. 
blood  changes  after  hemorrhage  of,  50. 
birdshot,  of  scalp,  391. 
bullet,  of  small  intestine,  745. 
of  stomach,  745. 
topography  of,  29. 
contused,  absence  of  hemorrhage  in,  6. 
gangrene  in,  7. 
of  abdominal   wall,  694. 
of  scalp,  390. 
shape  of,  7. 
contused   and  lacerated,  5. 
character   of,   5. 
diagnosis  of,  7. 
infection  of,  7. 

injuries  of  blood-vessels  in,  6. 
diagnosis  in  examination  of,  392. 
diseases  of,  85. 

effects  of  severe  hemorrhage  of,  51. 
erysipelas  of,  120. 
complications  of,  122. 


INDEX    OF    SUBJECTS 


809 


Wounds,   erysipelas   of,   constitutional   symp- 
toms of,   121. 

onset  of  disease  in,  120. 
gunshot,  23. 

aseptic  healing  of,  29. 

of  abdomen,  735,  737. 

of  abdominal  wall,  694. 

of  diaphragm,  737. 

of  face,  447. 

of  heart,  640. 
diagnosis  of,  G40. 

of  intestine,  737. 

of  kidney,  737. 

of  lung,  G34,  636,  737. 

of  neek,  537,  604. 

of  pleura,  737. 

of  scalp,  391. 

of  wall  of  thorax,  629. 

produced  by  automatic  pistols,  33. 
hematogenous  infection  of,  1. 
hemorrhage  of,  47. 

from  arteries,  47. 

from  veins,  48. 
incised,  8. 

bleeding  of,  8. 

division  of  muscles  and  tendons  in,  9. 

division  of  nerve  trunks  in,  9. 

gaping  of,  8. 

of  scalp,  390. 

pain  of,  8. 
infected,  amputation  of  arm   for,   92. 
lacerated,   examination  of,   5. 

of  abdominal  wall,  694. 

of  scalp,  390. 
leucocytosis  of,  103. 

diagnostic  value  of,  104. 
lymphangitis  of,  94. 
nonpenetrating,  of  lung,  630. 

of  pleura,  630. 

of  thorax,  629. 
of  abdominal   wall,   693. 
of  blood-vessels  of  neck,   537. 
of  brain,  42S. 

symptoms  of,  429. 
of  esophagus,  543. 
of  external  eai-,  503. 
of  face,  447. 
of  heart.  640. 
of  hypoglossal  nerve,  542. 
of  intercostal  arteries,  630. 
of  internal   mammary  artery,  629. 
of  large  intestine,  748. 
of  larynx,  583. 

of  lung,  subcutaneous  emphysema  in,  634. 
of  mesentery,  744. 


Wounds  of  neck,  536. 

of  nerves,  fibroneuroma  from,  11. 

of  nerves  of  neck,  540. 

of  omentum,  749. 

of  orbit,  400. 

of  particular  blood-vessels   of  neck,  538. 

of  pleura,  subcutaneous  emphysema  in,  634. 

symptoms  of,  631. 
of  pneumogastric  nerve,  541. 
of  posterior  thoracic  nerve,  542. 
of  stomach,  untreated,  prognosis  of,  733. 
of  sympathetic  cord,  541. 
of  thoracic  duct,  542. 
of  thorax,  629. 
of  trachea,   583. 
of  veins  of  neck,  539. 
of  vessels  of  thorax,  629. 
open,  2. 

of  scalp,  389. 
penetrating,  of  abdomen,  732. 

symptoms  and  diagnosis  of,  733. 

of  great  vessels  of  thorax,  642. 

of  heart,  637. 

of  lung,  633. 
infection  of,  635. 

of  pericardium,  637. 

of  pleura,  631. 
infection  of,  633. 

of  thorax,   630. 
poisoned,  12. 
poisoned   arrow,  characters   of,  21. 

symptoms   of,  21. 
produced  by  artillery,  46. 

by   high-powered    rifles    of    small    caliber, 
firing  soft-nosed   bullet,   32. 

by  modern  military  rifles  and  pistols,  24. 

by   rifles    and    rifled    pistols    with    black 
powder  and  soft-lead  bullets,  41. 

by  shotguns,  43. 
punctured,  9. 

diagnosis  of  pyogenic  infections  in,  11. 

localization  of  foreign  bodies  in.   10. 

of  arteries,  10. 

of  nerves,  11. 

of  scalp,  391. 

of  veins,  11. 

signs  of  infection  in,   11. 
pyemia  of,   114. 

methods    of    infection,    114. 

varieties  of,  114. 
stab,  of  abdomen,  734,  735. 
subcutaneous,  1. 

of  scalp,  386. 

anatomical  peculiarities  of,  386. 
signs  of  contusion  in,  386. 


810 


INDEX    OF    SUBJECTS 


Wounds,  tetanus  of,  122. 

acute  types  of,   123. 

chronic  types  of,   123,   125. 

course  of,  124. 

invasion  of,  124. 

of  head,  125. 

subacute,  125. 
Wry-neck,  531. 
forms  of,  533. 
spasmodic,  533. 

Xanthoma,  250. 
X-ray  apparatus,  339. 
description  of,  339. 
current  in,  339. 
induction  coils  in,  340. 
interrupters  in,  341. 
Caldwell,  344. 

Wehnelt,   principles   and   construction  of, 
341. 
static  machines  used  in,  339. 
tube  of  Dr.  E.  Griinmach,  347. 
of  E.  Gundelach,  347. 
of  Queen,  346. 
tubes  in,  344. 
X-ray  burns,  382. 

after  single  exposures,  3S3. 
upon  X-ray  operators,  381. 
X-ray  diagnosis  of  deformities  of  bone,  369. 
of  dislocations,  369. 
of  fractures,  367. 

certain  limitations,  367. 
X-rays,  chronic  disturbances  produced  by  fre- 
quent exposures  to,  384. 
azoospermia,  384. 
epithelioma,  384. 
detection  of  biliary  calculi  by,  381. 

of  chemical  composition  of  kidney  stones 
by,  376. 
conditions  necessary  for  success  in,  376. 


X-rays,   detection   of   pathological    concretion 
by,  374. 
of  stone  in  urinary  bladder  by,  378. 
of  ureteral  calculi  by,  378. 
detection  and  localization  of  foreign  bodies 
by,  370. 
Mackenzie-Davidson  localizer,  371. 
Sweet's  localizer,  371. 
recognition  of  tumors  and  diseases   of  the 
soft  parts  by,  374. 
X-rays  in  surgical   diagnosis  in   injuries   and 
diseases,  367. 
technic  of,  348. 
details  of,   356. 
fluoroscope  in,  358. 
general,  of  radiography,  348. 
cervical  spine,  357. 
collar  bone,  356. 
compression  diaphragm,  355. 
distortion,  354. 
head,  356. 
hip-joint,  357. 
knee,  leg,  foot,  358. 
shoulder-joint,  356. 
spine,  kidney  region,  357. 
thorax,  357. 
making   of   X-ray   pictures   and    develop- 
ment of  photographic  plate,  359. 
stereoscopic  radiography  in,  360. 

apparatus   for  taking   stereoscopic   pic- 
tures, 361. 
apparatus  for  viewing  stereoscopic  ra- 
diographs, 364. 
method    of    producing    X-ray    pictures, 

366. 
methods  of  taking  stereoscopic  pictures, 
363. 


Zygomatic  process,  fractures  of,  471. 


(1) 


END    OF    VOLUME    ONE 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD35J62C.1V.1 

Surgical  diagnosis 


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